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w <br /> IC) <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 3rd <br /> (209) 468-3420 o r <br /> 14' log-AFFumnagiE PERMIT EXPIRE! 1 YEAR1 <br /> FROM DATE ISSUED <br /> APPLICATION 18{DERE BY MAO*TO THE SAN JOAW N COUNTY FOR Amplots PEIIu9T 70 COMSTRUCTAm D/OR INSTALL THE WOM Tr{pl mal <br /> 04 r <br /> JOAGUBN COUNTY DEVELOPMENT TILE-CHAPTER 9-1715.3 AND THE STANDARDS OF SAN JOAM N COUNT1r PUBLIC HEALTH SE BRVRC88IESNVIf OIMfENTk HMS��N ANCE WITH SAN <br /> JOB AOORESSMR APNN 574- G /�7•-jj 1.t1'iEafol p . <br /> CITY �(LkG <br /> ( 7 PARCEL 812EIAPN 3 X30_o f <br /> OWNER'S NAME L-E'Sf S�+� 1 c ? e, &M;.4 � BC f <br /> AA �/ I. S 19-' PHONE I. 6. .�lt'�JL- <br /> CONTRACTORS-J'S SG N�!Tx-r- 1.1�'11-1yl�fL I ADDRESS 9 F, `I'L 1�'L.�;'1 (iA ucl 4-k7Odv PHONE/StO L F <br /> PUB CONTRACTOR I..� r" �. J aI <br /> ADDRESS G' L.1CIG� � L (+HpNE><���Z•]i <br /> i <br /> Trema OF WELL/PUMP: ❑ Ww WET. ❑ REPLACEMENT WELL ❑'MONITORING WELL./ ❑OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ cR088-CONNECT REPAIR Q VAPOR EXTRACTION WELL. <br /> N. 11140.11N•P• DEPTH PUMP 8ET FT, � FIRST WATER LEVEL <br /> (TYPE OF PUMP) p <br /> © OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL s le-lk BORING a <br /> DESTRUCTION: <br /> INTENDED UfiE TYPE OF WEM CONSTRUC710H 8P*CWCATIONS <br /> ' A ' <br /> 0 WO ISTMAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION OIA_OF CONDUCTOR CASINO p <br /> ❑ DOMESTRCAPRIVATE ❑GRAVEL PACU ME TYPE OF CABINGISTEEUWC DIA.Of WELL CASINO D <br /> ❑ PUBLICIMUNIMPAL ❑DRIVEN DEPTH OF GROUT SEAL BPECIMATION R <br /> 0-1 ATIONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> © MONTOPINo GROUT REAL PUMPED: ❑Y. ❑N. CONCRETE PEDESTAL BY O ILLEM❑Yr ❑Na s <br /> APPROX.DEPTH LOCXRNG CHESTER SOXISYOVE RPE S <br /> PROPORED CONSTRUCTIONRNILULG METHOD: MUD ROTARY AM ROTARY AU M CABLE OTHER <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGVLATIONS OF THE SAN JOAGVDN COUNTY. INDME OWNER OR LICEHSED AGENT'S SIGNATURE CERTOTES THE PaUOWING:-1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 T O,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOM MAN'll COMPENSATION LAW9 OF CALIFORNIA.' CONTRACTOR'S WING OR SUB-CONTRACTMO SIGNATURE CERTIFIER! <br /> THE FOtUI CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIL18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIEMAN'S COMPIENIIAT1ON LAWS OF <br /> CAUFO THE DrAIFT T C HOURS W ADVANCE FOR ALL REOUIM WSPlCTION8 AT 12001 ADSA428. COMPLETE DRAW9M AT LOWER AREA PROVIDED, <br /> TWO <br /> PLOT PLAN ID,aw to Goal*Sod. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOVHDMO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,DIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION Of SEWAGE DISPOSAL SYSTEMB, <br /> 3. DNMENSGONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S- LOCATION OF WELLS VRTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOIN9M PROPERTY. ' <br /> F <br /> DEPARTMENT USE ONLY /. <br /> Applle*tbn Aava.tad 81 - .. Dat. :L3/ A,.*` v-P -A41 <br /> Gteut hupeetbn BY Dna Pump hwveetlan BY oat* <br /> De.tnteth-lnapactlen By -- ., 0.16 <br /> Cem,ner.er '�-1 Q <br /> ACCOUNTING ONLY: MDI FACJ ��O 1 <br /> FE CODES FEE INFO AMOUNT RERSTTTD C KlPCASH RECEIVED BY DATE P9IMITHERVICE REQUEST NUNSNI / INVOICE <br /> 3 <br /> Pub HeaM Se1V.-Enviro.173(1/97) <br /> e <br />