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�PPUCATION FOR WELUPUMP PERM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <br /> (M)468-3420 <br /> ROWREf>1MUM FUMIT EMM 1 YEAR FROM DATE ISSUED <br /> R:4wblr b Tr*GmIW <br /> APPUCATDM M IWE SY MAO[TO TM GM JOAOUIPI COUNTY Poll A.0" TO ODMfTI UCT AMOIOR NSTALL THE WORK DESCRSED.7148 APPLICATION 18 MADE IN COMPLIANCE WrTH SAN <br /> JDAOM tOLSISSrormomma 1TTM CPEAPTm 9.1115.3 Amp TM STANDARDS OF t�MJOACtM CO�UWNT//Y PP�UKX HEALTH SERVICES.EHVI IONMENTAL HEALTH DMSION. <br /> JOOA001lSMRA1SIE�G`l AF / 99 ,,04 0J 1 3as R�~. 80-" CITY I r°"^f PARCEL SCMAPNI ,6•'J�l`l�J <br /> p 1♦ {V/-'' AOORF= <br /> PHONE I <br /> — ADDRESS 2D UC/ PHONE I /-/3 C <br /> S�7LNT f'ZO <br /> INN P CSS ADDRESS �f. LIC# RHO/NEVI <br /> O owwwILL ❑Po AcvmcmT WELL ❑ LeowONNG WELL• QL OTHER U <br /> Q DWAUATAM ❑WHL SYSTEM PEPAJR ❑ CROSSCONNECT REPAIR ((JVAPOR EXTRACTION WELL/ J <br /> D ISwOII..Itr Iv. DEPTH PUMP BET FT. FIRST WATER LEVEL O <br /> ❑ovroF-4E1IVICE WELL ❑ oEovlHYtslcAL WELL I �toa BORING s <br /> " IOC <br /> CONSTRUCTION SPECIFICATIONS A <br /> Q ❑OPO/SOTTOM DIA_OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> O ORAVEL PACRM n TYPE OF CASINGMTEMJPVC DIA.OF WELL CASINO O <br /> IJ PvKwAmpecrft ❑01SVOR DEPTH OF GROUT SEAL SPECIFICATION R <br /> (3 wPEsmwllw ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAM NAME E <br /> O GROUT SEAL PUMPED: Cl Yr ❑Ne CONCRETE PEDESTAL SY DRILLER;❑Yw ❑Ne S <br /> t . :S1SlEM LOCKNO CHESTER BOXISTOVE PIPE S <br /> METHOD: MVD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> �4A or <br /> j1lMWe§PWWV THAT I HAVE~^RED THIS LIBE <br /> S APPCATION AND THAT THE WORK WILL DONE M ACCORDANCE'JOAOUIH COUHNIY ORDINANCES,STATE LAWS.AND RULES AND <br /> MaKft"M M"M SM JOAOUN COUNTY, NOME OWNER OR LICENSED AGENT'S MHATURE CERTIFIES THE FOLLOWNG:•1 CERTIFY THAT N THE PERrORMANCE OF THE WORK FOR WHICH <br /> 1�0�0=81M 1 ONILL NOT OMPLAY PERSONS SUBJECT TO WORK MAWS COMPEMSATION LAWS OF CALIFORNIA CONTRACTOR'S HM M OR W6.CONTIIACTDM t1ONATURE CETRIFIE6 <br /> "it POWWOW '1 CMIP V THAT N THE PERFORM ANCE OF THE WORK FOR WHICH THIS PERMIT It ISOM.I SHALL EMPLOY PERSONS SUBJECT TO WOIOOMAN'S COMPENSATION LAWS OF <br /> sompeow.1S♦ Y1 IN ADVANCE FOR ALL REOMIGI)POSPECTIONS AT 1`204)444-34M COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> ,...._ ' +ItP•i <br /> T. <br /> PLOT PIAN ID,—n S—W Sei 'is <br /> y lk MOM"V omplim SSI RDAOS 11E/1IElT TO 011 BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> MWAN W 104PI110POWY N �9P <br /> OVO NONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> It L ACRO LACATHDM OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> COVE"MEAS SUCH M PATIOS.DftVEWAYB,AND WALKS. ON THE PROPERTY OR ADJOINING PROPEHI'Y. <br /> A.l`I"PRTrca. .�.,. 4._,.T...._i._..i......a......... .. ...� .. <br /> rt. ....I...e '. ..{.. ..:............. .... .. .... ... ..{.. .... ........ ........ <br /> } ' <br /> AL <br /> MY �. . <br /> I <br /> IL .4 :..... <br /> DEPARTMENT USE ONLY y, <br /> APPlleallon Aeespted 9Y l�D^ 1����`�1 d DH• 5K Aye' <br /> Great Impeetlen By �^ • ��R/� Det. 6 u P> p Irup—tlen BY Owe <br /> - <br /> ow <br /> De.tnwllen I—P—IIn By <br /> Cemmenlc <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE P131MITISUMCE REQUEST NUMBER INVOICE <br /> Pub.Heafth Serv.-Enviro.173(1/97) <br />