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APPLICATION FOR UBUCWELJ-IPUMP PERMITWs ELL <br /> SAN JOAQUIN <br /> ENVIR COUNTY PUBLIC HEALTH SERVI <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 �}.1 r�n /7 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED \\, <br /> / <br /> fLSIf1AIIfI M TfIPD66tI) 1 , <br /> APPLICATION IB HERE MY MADE TO THE BAN JOAO"COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WDM M6CRIBED.T108 APPLICATION 18 MADE IN COMPLIANCE WITH 8AN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.11 6.7 AND THE STAND F SAN JOAQUIN COU PUBLIC IIEALIH BE FO,ENVIRONMENTAL HEALTH DIVISION. 1 'V <br /> JOB ADOMSS/OM ANIW CITY PARCEL BIZElARlIoI l -� I V <br /> OWNER•I NM . moom F3&4-� <br /> CONTRACT � "$6FN <br /> BUR — <br /> CONTRACTOR Al)LRES6 IFDI P//ONE F <br /> TYPE OF WELUFLIMP, ❑HEW WELL ❑REM.CEMEW WELL ❑MONOORNG WELL I ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CMGONNECT REPAIR 11 VAPOR EXTRACTION WELL F J <br /> ❑N«v❑R.PW H.P. DEPTH PUMP SET_FT. Frw WATER LEM O <br /> (TYPE OF PUMPI <br /> OUT-0F-SERVICE WELL ❑OEOPffY We AI WELL P ❑ 80IL DORINO B <br /> 'X DERTRUCTIOW <br /> //INENDED USE TYPEOF WELL CONE MVCTON IIEC CATIORS A <br /> T <br /> ❑IHOUSTRAL ❑OPEN BOTTOM DIA_OF WELL EXCAVATION DIA.OF CONDUCTOR CAB IND D <br /> E]DOMEITICMRIVATE ❑GRAVEL PACK/SIZE TYPE OF CA8INGMTFFLP VIA,OF WELL CASINO p <br /> El PVSLIC/MUMCWAL ❑VrvwN DEPTH OF GROUT SEAL SPECIFICATION q <br /> ❑IRRIOATION(AG ❑OTHER GROUT SEAL INSTALLED BY OFIOUT SPAM NAME E <br /> ❑MOMTORNO GROUT BEAR PUMPED:❑Y.. Cl N. CONCRETE PEDESTAL RY ORILLEIL❑V.. ❑Ne S <br /> A".X.OMN LOCKING CHESTER BOXMOVE PPL <br /> 5 <br /> MOMOM CONSTRUCTION/ Lll O METHOD:MUD ROTARY AIM ROTAFW AUGER CABIJEOTHER <br /> I HE"BY CERTIFY THAT 1 PIAVE PREPAFWD TMS AIELICATKHN AND THAT THE WOFK WILL BE DONE M ACCORDANCE WITH BAN JOAQUIN COVNTY ORDINANCES,STATE LAWS,AND RUES ANO <br /> REGULATIONS OF THE BAN JOAOLIIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICN <br /> TIOB PERMIT II ISSUED,I SHALL NOT EMPLOY PERSONS BLRBJECT TO WOHOMAN'f COMPOFSATON LAWS OF CALIFORNIA.'CONTRACTOR'S HIRNG OR SU"ONTRACTMG SIGNATURE CERFIFES <br /> illE <br /> FOLLOWING: '1 CITIFY THAT EN THE PERFORMANCE OF THE WORK FOR WHICH TMB PEFART 18 HK".I SHALL EMPLOY PERSONS SUBJECT TO WMKAIAN'S COMPLICATION LAWS OF <br /> CALIFORNIA.' A RMV CARL U HOURS IN ADVANCE FOR ALL REdMRm MSRC //S��AT,FIIGII ACC.SAlt.COMPLETE DFLAWIHO AT LOWER AREA IAOV"O. <br /> 04-1 I TPM. y E�[t^� D.H )-21^�F`DO. <br /> PWT PLAN D...r 1.S•r.l 6•.I• -le <br /> 1,NAMES OF STREETS OR ROAD$NEAREST TO OR EOUf1IXNO THE PTOKRTY. S. LOCATION OF/OUSE SEWAGE DISPOSAL SYRTEM OR P MGPID <br /> S.OUNE TLIOf THE PROPERTY,GIVIfM DIMENSIONS AND NORTH OIECTON. EXPANION OF SEWAGE DIIPOBAL SYSTEMI. <br /> 7.DIMENSIONED OVTUNFS AND LOCATION OP ALL EXISTING ANO ROPOSEO I,LOCATION OF WELLS WITHIN RADIUS OF ONE HUNdED FIRM R, <br /> STRICTURES,NCLUDINO COVERED AREAS SUCH AS PATOS,OrfVEWAYB,AHD WALKS. ON THE PROPERTY OR ADJOMMO IMMOIERTY. <br /> .. .. <br /> ....:..... ...i. ... stv. .: .. <br /> p. : . ..`. : . AYMENI <br /> f <br /> :. RE r <br /> CEIVEE) <br /> � <br /> , .. DEC:2 Y 2000 <br /> .` SABLICOLrN EOUNI u <br /> PUBLIC ENL FIS RVICES <br /> NVI <br /> ONIICNTAI HEALTH DI <br /> 1017�5A <br /> - -- <br /> — — 1 <br /> ARTMENT VFL ONLY <br /> .. ACPS..tbn Aee•.I.d BY \_��� l A ` I �/�J��"��W- D.1• I �l• "1/ /vr� <br /> G—Mpmllo�.By oH. RAnP lo•P.•M.o 8, v.I. <br /> �I o•.I,..a•„hP.albn er / o.I. <br /> C•� / <br /> .CCOUNTINO ONLC AIRF FRCP <br /> PI CODES FEE INTO AMOUNT R TIEDCIECKE ASH ntcovED BY OAT Ferre Trf H1 OVUT ■F11 INVOICE <br /> f l — lads 'V cc) <br /> W tom- O �a LLE S <br />