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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> MDR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICempleIS M TrIpDRBIRI <br /> APPLICATION IB ITEM BY MADE TO THE SAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WTTII SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.111[5/3 AND THE STANDARDS OF BAN JOAOUIN COUNTY MIRIC IIEALTII SERVICES,ENVIRONMENTAL IIEALTII DIVISION.. <br /> JOB AODMSRMR AM- 193-J 0 /If DW r J.4L KI CITU PARCEL SIZE/APNII PSE <br /> W <br /> OMn'S NAME ADORES• \���YDE'\ y MMW /E-)ye[�{�[) <br /> CONIMCTOR ,'jjq AODREBB�L' J• I y� LTC) 7� 1110NE 1 3t,+.j - �/ / <br /> BUB CONTRACTOR ADORSS EIC/ PHONE <br /> TYPE OF WFLIA'VMP• KNEW WELL ❑ PEKACEMEM WELL ❑ MONITORINa WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CM99,CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> ❑NwV❑R.etlr H.P. DEPTN PUMP BET�FT. FlRBT WATER LEVEL <br /> H _ n <br /> YPE OF P/MPI �``------ <br /> ❑ our OF-SERVICE WEIt ❑ GEOPHYSICAL WELL/ ❑ BOR BORING B <br /> ❑DESTRUCTION: <br /> EN IENOED ME TYPE OF WELL coN6TRUCTION SPECIFICA1—IONS 'T�P A <br /> ❑ INDUSTRIAL ❑OPEN BOITOM ' DIA.OF WELL EXCAVATION /,` DIA.OFCOMMTORCARING n <br /> p❑(MMEmICTPoVATE ❑GRAVEL PACKISIZE. TYPE OF CASINOIBTEEL/I'VC� DIA.OF WELL CASINO <br /> /MD <br /> Jf.I PIBIkUMCMAI DRIVEN DEPTH OF GROUT BEAD SFECOICATION I R <br /> /❑ MRIOAIgN/AG ❑OTHER GROUT REAL INSTALLED BY 1)"n, BMW BRAND NAME cD4 L41--,crQ E <br /> ❑ MONITOMNO / GROUT REAL MIWKV:A Ys ❑N. CONC1RETEKM9TAL8YDRLLER!; Y•. ❑He S <br /> �APPNOX.OEM" O ��1///��� LOCKmO CHESTER aOX/TOVE PPE S <br /> PROPOSED CONSNeLK:TION/d1LUN0 METHOD: MUD ROTARY AIR POTAM AUGER CARL- OTHER <br /> H IIERFSY CEn1MY THAT 1 HAVE PREPARED THIM APPLICATION AND TIIAT TIM WOR(WILL BE GONE M ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES.STATE IAWe.AND MILER AND n <br /> MrIMATION 1 OF THE BAN JOAGOIN COUNTY. Now OWMR OR LICENSED AGENT'S SIONATUM CERTIFIER TNM FOLLOWING:'1 CFMIFV THAT IN TIIE MWORMANCE OF TIIE WOIR FOR WI11C11 <br /> TIIIR"MIT IB 1990ED,I SHAUL HOT EMPLOY KnOONS SUBJECT TO WORKAIANY COMPENPANON"WS OF CALIFORNIA.- COMPACTOR-9 IRRINO OR BUB CONTRACTING SIGNATURE CERTIrIEB <br /> TOE rOLLOWING: '1 CERTIFY THAT M TINE KSTORMANCE OF TRE WORK FOR WIIICII 111I8 PERMIT IB ISSUED.1 SHALL EMKOY PERSONS RURJFCT TO WORKMAN'S COMPFRRANON I We OF I� <br /> CALNORHIA.'' T1RAAAPMMUUUCCCANA..NJNI M/OST CAALLL,JE�1 MUM IN ADVANCR FOR ALL PROMISED IN/S//��JC�TIONS AT 110814NiIlS. COMPLETE DRAWING AT LOWER ANSA PDVID D. y <br /> Sq,+d% ,/n TIII. /"• 1 Do. / F)n, <br /> PLOT RMAN I.le BeJn Be•H 'le /�. <br /> 1. NAME@ OF TPEETS OR ROADS NEAREST 10 OR ROUNDING TIIE RDPERTY, A. LOCATION OF NOUBE @MADE DIRMOAL SYSTEM On P MIMD In <br /> 1. OUTI.MIE OF TIM PDKIOV,OWING DIMENSION@ AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> M. DIMENOIOMO OUIUNEB ANO LOCATION OF ALL EXIWINO AND P M@ED S. LOCATION OF WELLS MTION RADIUM OF ONE HUNDRED FIFTY <br /> STRUCTURER,MCLUOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAOt S. ON THE P MISTY OR ADJOINING POMIT Y, <br /> ♦\ �� `FJ J <br /> 131998 <br /> DEPARTMENT USE ONLY <br /> APPM.Nbr Aw•PI.S BY /D/ByyY./. N. <br /> m«A B..PeeN.rl sr Dn PAR/InpsING erE. <br /> D..m�Ilerr Iwn•vlbn Br Da. <br /> tnmenPxe <br /> ACCOUNTING ONLY: mot FACS <br /> r1 COORS TEE INTO AMOUNT 11"1/10 CeHEC /CABII I RRGDVM MY DATE rO ii,NV1C■PEOUE/T NUMPHI INVOI[F <br /> w;tu- Ila 1KID <br /> Pub.Health Se".-Enviro.173(1/97) <br />