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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O,BOX 385,304 EAST WEBER AVENUE,STOCKMN.CA 9MOI388 <br /> 1209)468.3420 <br /> RON-AEFDMOABLE PERMIT EXPIRES 1 YEAS FROM DATE PSSUEO <br /> tGwplw ID TriFRob} <br /> APPLICATION IS HERE BY MADE TO THE SAH JOAOWN COUNTY FOR A PFPMR TO CONSTRUCT ANMR NSTALL THE WORK OESCNNS SEO.TIAPPLICATION IS MADE N CTA�LIANCE NTTH DAN <br /> JOAQUN COIAYTf DEVELOPMENT TITLE,CKAFTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUIUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, <br /> JOS ADOMAWOR APIYyo 3s s r Ale/I L,:4 e_ d" —CRY <br /> `l i-G�/ -(�"�. 6:�J7 P K <br /> _ 'A ' yryU•¢�7`..S?�O�N2GQr �P`Z'E6ITAt0PlWfEJ <br /> OYIER'S NAME ADDRESS <br /> COMPACTOR ♦ ��GS <br /> Sf1V0d <br /> c/f cZ ADDREes d �f0�!✓�•• I"3//nAac's.�Jl uct �3!/ PNONEf .J�G'`ll/�e <br /> DUB CONTRACTOR ADORED✓! �/ /a. �UC, Roof, <br /> TYPE OF wu)pL A . ❑NEW WELL •�❑REPL^CEJAENT WELL e ❑MoNRORNO WELL f ❑CTHER <br /> (7 / ❑IJSTAI:•ATION ❑WELL SYSTEM REPAIR ❑CROSS•CONEIECT REPAIR ❑ VAPOR EXT•AACTION W!LL I •� <br /> IRHwe❑a".1, H,P. DEPTH PUW SEI_6k_FT_ FIRST WATER LEVEL 9 T—_ d <br /> (TYPE OF PULSPI <br /> ❑OUY-Or&EAVICE WELL ❑GEOPHYSICAL WELL 1 ❑ SOS.AORNRI S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE CONSTRUCTION A O A <br /> ❑INDUSTRIAL ❑OPENBOTTOU dA.OF WELL FJICAVATION TAA.OF CONDUCTORCASDIO D <br /> ❑DOME$TICRRVATE ❑GRAVEL PACK1DfLE_ TYPE OF CASMISTEELVVC ORA-OF WELL CASIW D <br /> ❑PUSUC,tAUNICIPAI ❑DRIVEN DEPTH OF GROUT SEAL _ SPECIRCATION A <br /> ❑FS ICATOOKIAO ❑OTHER GMUT SEN.NDfALLrD BY OMVT SPAM NAME F <br /> ❑MONRORFIO OROUT SEAL PIMPED:❑Vee ❑Ne CONCAM PEOMAL SY DSL,m•❑YM ❑Ne s <br /> APPROX.OEIIN LOCKBM CHESTER SpXA ITOVE PIPE_ D <br /> PIOPOSM CDARTICXIFICK AILLIN4 METHOD: MIA ROTARY NR ROTARY AUGER__GABLE OTHER <br /> 1 W-t[BY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOLRN COUNTY OR'DINANCED,STATE LAWS,AND BRED AND <br /> REGULATIONI OF THE SAN JOAQUIN COUNTY.NODE OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THF EOER <br /> LLONANG: I CTIFY THAT N THE PEW-ORAANCF OF THE VV019K FOR WHICH <br /> M <br /> THw PERT IS ISSUED.1 SHAIL NOT EMPLOY MACHO SUBJECT TO WORIGAAW S COMPS"ATION LAWS Of CALIFORNIA'COMRACTO"Hrim OR OM--OHITVI.CTRIG SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT M THE PERFORUANCE OF THE WORK FOR VANCH THIS PERMIT IS"UM,1 w1ALL.EUROV PERSONS SUBJECT TO wORIPEAM7 COMdSATIOR LAWS OF <br /> CALIFOIMA.' : ANT MUST CALL 24 IIOUIS W ADVANCE FOR ALL RlOtwt�9"P=110119 AT 12o7o 4so4426.COWUM GNAWING AT L.OWOR AREA PRDVrIOW, <br /> SiyW X .I <br /> ROT MAN{Drew to G.-AA a. 'Ie <br /> I.'NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDIRG THE PROPERTY. 4. LOCATION OF HOUSE SEWAOE DISPOSAL SYDTEIA OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY.GIVING WMEND70N8 AND NORTH DIRECTION. EXPANSION OF SEWAGE ORSPDSAL SYSTEMS. <br /> T. DIMENSIONED OVTUNFS AND LOCATION DF ALL LXIMNG AND PIIOPOSM S. LOCATION OF WE14S WWTMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLVDMG COVERED AEE"SUCH AS PATIOS,DRIVEWAYS,AND WALK$$��,j, 1ON THE IN <br /> PROPERTY OR ADJOWO PROPERTY- <br /> . �J 2AI�irf/J <br /> , <br /> M1 2 21997 <br /> iLIr`iIiA <br /> LxP Sl:FiUIC#a <br /> ..ENVIFl0WSEP'.'ALHE,4LT.4J JISICON. <br /> i <br /> DEPARTMENT UST,ONLY A. lto btl Aoo pl A By_ DRw Ams <br /> Oral Irpeatlert By ONe AIIy MI.p.01bR Dy OSOS / <br /> DYIruallen IISI,ctb:By EIYL. <br /> Corte_: <br /> KCOUNTINtl O/(Y: AID/ FACE <br /> ►E COO)ES FU ILIO —CURT RIlATTM CN 1CA8R1 RSCDVED IY DATE ItEOWT NUMIw INVOKE <br /> y <br /> -sipa a <br />