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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 9 BOX 388,446 N.SAN JOAQUIN ST,STOCKTON,CA 96201-388 <br /> (2091488-3420 <br /> r7 /� NON-REFUNDANLE PERMIT EXPIRES 1 TEAM FROM DATE ISSUED <br /> c.._M^-n �C QQ-`' •� ICwgl{I{L TriploBn) <br /> APRICATION IS HERE BY MADE TO THE SAN JOAOUN COUNTY FOR A PEA.fT TO COW DUCT AND,OR WSTALL THE WORK DESCRIED.TWB APPLICATION TO MADE IN COMpUJ NCE WITH&W <br /> JOAd104COUNTY DEVELOHIEHT TITLE,CHAYI-Ea 8l1�11 6.3 Allo THE STANDARDS OF SAH J\OA O PUBLIC H�E/1/LTH SF)MCEB.ENVIFIONMENTAL HEALTH dN SION. A <br /> JOB ADOHE.'+epR APHI /—/ / 3,3 3 W C �d Com:/In/•. / PAl/ICER BLZ APA.���/�C <br /> OWNER'S NAM'.yLLLL'L(,ll�C. S �1 c.AOOFESl S�)3 Lc. zc,1 17w` O l�� FPf I <br /> coNTRACToa��a L i7 �.t L A.D.. P q/7 1?,z. a UCI <br /> SUBCONTRACTOR_ ADORES UCI _PHONES <br /> TYPE OF WELLPRAAP L'NEW WELL ❑REPLACEMENT WEIR ❑MDNrTGUNG WELL I ❑OTHER - <br /> ❑--I 1BTALLAYSTEM nO. ❑WELL SPC— 1:1FN <br /> CROSS-COECT REPANR ❑VAPOR E%TF.ACTYJN WELL <br /> �+� / ✓ <br /> ' 0 � <br /> N—cup—* H.P.�L� DEPTH PUMP III o FT. FIRST WATER",X � 0 <br /> (TYPE OF PUMPI <br /> ❑ovroF-SERVICE weu ❑GEOREYucAI vYEu I ❑_ B � <br /> ❑ceETIRACTON: ��(�l <br /> I NTENOFD USE PE OF WUL CONSTRUCTION♦PECIFTCA.TIONS A <br /> ❑IHOUSTFJA ❑OPEN DOTTOM DIA OF WELL EXCAVATION d/l OF CONDUCTOR CA81NO D�' p <br /> ❑DOMESTICAPNVATE ❑GRAVEL P—VWE TYPE OF CASNGIRTEELM/C DIA.OF WELL CASINO D <br /> ❑PURLICRRUNa PAL ❑DRIVEN DEPTH OF GROUT SELL SFECIFICATION R <br /> INIIGATIOWAG ❑OTHER GROUT SEAL NETAILED SY ORDUT BRAID NAME �-1 E <br /> ❑MONITORING G L,T SEAL PUMPED:13 Y- 11 No CONCRETE PEDES'AL BY DNLLFA❑Yw ❑NP S r <br /> AFFROIL DVTH I O E? _ LOCKING CIESTER WXNTOVE PIPE $ d(O�- <br /> PFLOPOSED CORUTRUCTIONRRSWNO MIETHom MUD ROTARY NR ROTARY AUGER CARLE OTHER {' <br /> I HEREBY CERTIFY THAT I HAVE Pr1EPAAF.D THIS APPUCATON.ANO THAT THE WORK­BF DONE IN ACCORDANCE WRTA BAN JOAOUN COUNTY ORDINANCES,STATE LAWS,AND RILED AND <br /> REODUTNINR OF THE SAE JOADWN COUNTY.HOME OWNER OR LICENSED AGENT'S S"ATLA E CERTIFIES THE MLLONWG:'I CERTIFY THAT N THE PEIEOpRANCE OFTHE woo IDR WNTCN <br /> TW R FERMR IS ISGUED.I SI NOT EMPLOY PERSONS WIRLIECT;'O WO#BUTAN'e COMPLAISAIRON LAWS GF CAUFORFAA.'CONTRACTOR'S HRilO OR IRWCONTRACTING 01ONATURE CERTIFIES <br /> THE FOLLOVANO: -1 CERTSI'THAT IN THE PEFFORMANC OF THE Y FOR WHICH THIS PERMIT IS ISSUED.1 SH/.LL EMPLOY PERSONS BULIECT TO WORIDAAN'S COMFDLSATION LAW%OF <br /> CALFORNA.' AR'UCANT MWT C No 11 VANCE YOR ALL R{GESIIm IN&MMNS AT 1] 1 Ate/. 23.COMPLETE DRAWSB AT LOWERS AEA PROVIDED- <br /> PILOT FLJw ID, <br /> PILOT ew.I TNaM <br /> 1.NAME8 OF In B GIR ROADS NEAREST TO OR BOUNDS-THE PROPFFRT'. J t.LOCATION OF HOUSE SEWAGE DIBPOBAL SYETQE OP F'ROF06m <br /> E.OURIIE OF THE PROPERTY,Grv*4 DIMENSION{APO NORTH dRECTIGN. FXP.ANMN Of SEWAGE DISPOSAL SYSTEMS. <br /> 3.DWENBIONEO OUTLNES AND IDCATON OF ALL EXISTING AID RD{O6lD {.LOCATION OF WELLS WTTWN FIAMM OF ONE HUNDRED RFT'FT. <br /> BTRIR,TURES,NCLUDING COVERED AREAS SUCH AB PATO e,GI ANU WALI(S. ON THE PMPERTY OR ADJOINING PROPERTY. <br /> ... .o........ �� .. ..... I .. . <br /> I . <br /> IN <br /> BEY' <br /> PAYMENT <br /> O e� RECEtvrn <br /> __ .. . <br /> SEP 1 3 1995 . <br /> SA <br /> � +; .pUB1 UIN.GUu <br /> ADI <br /> _ A. C hEALTH SERVIGEg <br /> – — 1RC�N <br /> ALTH Div1gF" <br /> ILL- <br /> UEPIVITMENT WE ONLY <br /> AYFS.r4n AeoePNd BY_ D.t �_Mw <br /> G­S.Pwd..,BY D.I. P—P In•I..�Ibn BY M11 0. Q 9.f <br /> Drnwlbn InpcUm BY,C-:-TNG ONLY: .VDI FACT <br /> R COVES FTE SFO AMOUNT RBAITTm CNBC ASH RR:HNm SY DATE FHB/TIaRIVICE R[Ol1FIT NIAYIBNR INVOICE <br /> rasa,00 1-7 9/l3 oa��95-b <br /> 1 <br />