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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAMN COUNTY PUOUC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 398,446 N.SAN JOAWN ST,STOCKTON,CA 962013EB <br /> (20 468-3420 <br /> NOW NfFUNDABLE PfRMfT fXPIRES I YEAR FROM DATE ISSUED <br /> IGi1PI6u h Tiokld) <br /> AFPUA'ATIDN IS HERE BY MADE TO THE BAN JOAOURN COUNTY FOR A FEFWIV TO CO NSrRUCT AND�OR WSTALL THE WGM DESCRIBED.THIS APPUGATION IS MADE IN C01.11FUANCE VATH SAN <br /> ,10^013WCOLMITY DEVELOPMENT TULE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN-AO COLINTv PUB HEALTH VICES,ENVIRONMENTAL HEALiN OINBON. <br /> JOB ADDPESSNft AWLF TTY [OT to wi PARCEL SIZEJAfNt_ <br /> OWNEfiS NAME L ADDRESS <br /> nn PHONE/ <br /> COHTRACTDII ADDRESS OET�IiCF��/n 'HONE/���_ r' <br /> SUB Cown CTORVADOPESE UCp PHONE I <br /> TYPE OFyxumwM- L NEW WELL ❑1FPLACEMENT WELLrE❑MONR-COFWO WELL/ D OTHER <br /> C]INSTALLATION ❑WELL SjYS,TEM REPAIR L{CPUS9ONAECT REPAIR ❑VALOR EATRACTV N WELL/ J <br /> 0N•M'QiRep.�, H.P. / ,! DEPTH PUMP SE F. FiRGTWATERLEV!-L <br /> I PE OF R/MPI ""Yrr[bb+----" <br /> ❑CUT DF.SMV(CE WELL ❑SLOP IY9 CAL WELL R y BOR BOW W: g <br /> ❑DESTRUCTION.- N <br /> I !_ <br /> INTENDED UBE FIYPE Dc WELL CONiTA11CTION iPECOTC AT10Ni A <br /> ❑INDUSTRIAL L10PEN$OTLDM DIA.OF WE'LL EXCAVAT)ON DIA.OF CONDUCTOR CASING p <br /> DOMEBTICIMVATE rOGRAVEL PACk SIZE TYPE OF CAS1NGi5TEFUPVC DIA.JF WELL CA6ME7 p <br /> ❑PUSLICIMUNICIPAL ALT DRVFI( DEPTH OF OFICUT SEK &PECIFICATJQN R <br /> ❑❑E�1APFI ATONlAO ❑OTHER GROUT SEAL INSTALLED <br /> T�BBTY GROUT iRAND NAME T-T E C� <br /> U MONRSO G OFOUT BEAL.RIMPED�L.JY- ❑% COMFIETEPEDESTALBYDWLLFWLIYee ❑Ne S C <br /> APFFIQX DEPTH _ LOCAING CHESTER B01L'STO VE PIPE___ S fS <br /> PFIOPCFED 1O"T1WCT14NlDpIWN4 METHOD:MUC ACT ARY NA AOTAAY AUGER__GABLE OTHER <br /> HEREBY CERTIFY THAT 1 NAVE PREPA/t0 THIS AFRICATION.AND THAT THEWCFV(WILL Be DONE IN ACCORDANCE WIPN SAN JOAQUI N COLMTYORDMANCES,STATE LAWS.AND RULES AND <br /> PEOULATION9 OFTHE SAN JOAQUIN COUNTY'.NOME DLYN'EA LR LICENSED AOEFIT•9 SIGNATURE CERTIFIES THE FOLLO>CNG:•I CERTIFY THAT W TINE PEWCHWAALCE OF THE WOO(FOB WMCH <br /> THIS PERMTr 18 ISSLi_D,I SHALL NOT EMPLOY PERSONS SUBJECT"0WORILMAN'S COMMIATfON LAWS OF CAUFOFN.IA.-CONTRACTOR'S HIRING OR BIALCOMRACrINO SIGNATURE CERT 16 <br /> THE FOLLOWING: IFY THAT IN THE PERFOA CE OF E MRI<FOR W'IICH THAS PERMIT IS)SSVED,1 SHALL EMPLOY PERSONS SUBJECT TO WCIIIOAAN^F COMPENS N LAWS OF <br /> CAL:FO T NT CALL 2A W CE FON ALL REGMRED IN l N!AT 120FI Atl-SF2S.COMPLETE CM WNG AT LOWER AREA PROVIDED. <br /> b�w+a k <br /> nll• <br /> PLOT RAN IDA !.S-k)SwF <br /> 1.NA OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPEAT�. L.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR pROpOBED <br /> 2�OUTL NE OF THREE"II GIVING DIMENSIONS AND NORTH DIRECT)ON. EXPANSION OF SL}VAOE DFSTDSAL BYSTFJAB. <br /> J.OIMENSONED OUTLINES ANO LOCATION OF ALL EXISTING AND M\OPU6FD 6.IACATON OE VvE11F WTTMN RADHIB Of CNE NUNDR'D FIFTY FT. <br /> STRUCTURES,INCWDING COVERED AREAS SUCH�q PATIOS,DRIVEWAYS.AND WALKS, ON THE PHOPFFTY Off ADJOSN(NG FfOPEHFY. <br /> I <br /> PA YMI ENT <br /> i <br /> �tOaS� <br /> SEPI 3 1985 <br /> CMDU-7f L L. <br /> I :- <br /> r�;a�.Ic <br /> 1r DEPMTMENT USE ONLY L JIyIt <br /> - TF•t• Alar <br /> G—lupe i—By -_,_ PIm.P L�•Pr%vfMl By (.LL[. / <br /> Ikr We,lm Irrpxtlon By_ <br /> D.ro <br /> Commw, <br /> ACCOUMTINJ GNLY: AIDI FAC/ --' <br /> R CGCeJI FEFINLO AMO[NT ROWTTTEO CHECK:CMH RbOgVm 7Y LATE PEI►A7,-FFEy10E REOUWT NUNFR WVG C/ <br /> C 5211 r?31k r ill- G� r Q <br /> S OObr120 <br />