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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> @ ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> Impute In TripReata) <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> 1 ; JOAOUIN COUNTY DEVELOFM Hi LE.CHAPTER 9-1115.3 ANO THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> R�JI JOB ADORESSfOR APNR <br /> i1wer CRY O PARCEL SIZEMPN! 4e <br /> OWNER'S NAME <br /> I ADDRESS f � P1fONE I <br /> FA] <br /> CONTRACTORADDRESS LICp1IONE. <br /> RM CONTRACTOR ADDRESS. UCS PHONE <br /> k <br /> 1 T1fPE OF WELLIPUM1 <br /> WELL ❑ REPLACEMENT WELL ❑ MOWORNG WELL I ❑ OTHER <br />'', .a `q BfSTALIATIOH ❑ WELL EM REPAIR ❑ CRSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br />? yN.�❑Repak H.P. DEPTH PUMP S£TFT. FIRST WATER LEVEL O <br /> R VPE O ❑OVT=OFSERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORIRKr S <br /> 4 J <br /> ❑DESTRUCTION: <br /> M INTETIDEO ViE - TYPE OF WELL CONSTRUCTION aPEC1FICAiIONi N A <br /> 1 ❑ <br /> INDUSTRIAL ❑OPEN BOTTOM t DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO / 0 <br /> DOM£STfCfiMIVATE ❑GRAVEL PACKMZE %1 TYPE OF CASINOIST£ELRVG_ �„ _ DIA.OF WELL CASINO 0 <br /> PUBLICIMUNICIPAL ❑DRVEN DEPTH OF GROUT SEAL SPECIFICATK)N "Aw <br /> ❑'MIIOATIONIAO ❑OTHER GROUT SEAL INSTALLED By GROUT BRAND NAME / E <br /> t I ❑ MONITORING - z GROUT SEAL PUMPED: WYw ❑Hs CONCRETE PEDESTAL BY DPol1ER Yw (3m. 5 <br /> I � <br /> t <br /> APPROX.DEPT [ LOCKING CHESTER BOXISTOVE PIPE s <br /> PROPOfft�CON STRUCTIOWDRILIINO MUH00: MUD ROTARY AIR ROTARY AVO£R CABLE-OTHER <br /> 1 <br /> 1 HE-IEBY CERTIFY THAT 114AVE PREPARED THIS AFYLICATKIN AND THAT THE NIOfK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY OFMM^NCEB,STATE LAWS.AND RULES ANO . <br /> gEQUTATIONB OF THE SAN JOAOUIN CV VNTY. HOME OWNER OR 1JC€kSEO AOENf'd SIGNATURE CERTIPI£8 THE FOILOWMIO:'t CERTIFY THAT 1N THE PERiFQRMANCE OF THE V4'OPIK FOR <br /> WHICH <br /> THIS PERMIT 16 ISSUED,1914ALL NOT EMPLOY PERSON@ SUBJECT TO WOPM.AN'd COMPERRSRTIOM LAWS OF CALIFORNIA.' CONTRACTOR'@ HIRING OR GM-CONTRACTINO MATURE Ct"ttmB <br /> THE FOLLOWING: 'I CERTIFY THAT IM THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT re 10SUM 1 SHALL EMPLOY PERSONS SUBJECT TO WORIONAM'S COMPERSA N LAWS OF <br /> CAUFORHIA.' T A �eAtLIRO VR`IM ADVANCE FOR AlL RIfOVI1ED M1i}t?GT10Na AT T"a}4"."" COMPLETE ORAWPM AT LOWER AREA PROM O. <br /> x � 91;9- <br /> two <br /> PLOT PLAN 1010 to Serial t1allo 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPER". 4. LOCATION OF HOUSE fiEWAKif OIdPOdAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.OPJM DIMENSIONS AND NORM DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> d- 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AMD PROPOSED S. LOCATION OF WELLS Wl"M!RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOMIFIG PROPERTY. <br /> ff <br /> V, <br /> ........... <br /> a m... <br /> V, <br /> i <br /> J . <br /> _ .. <br /> i <br /> o <br /> ..,. .. ...� .. .. ,.. �T ' 9,1993 <br /> s. <br /> `ak�i�.1CiAQlJI1V LOU 7` : <br />