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PLICATION FOR WELLIPUMP PERMIT <br /> SAN J ACUIN COUNT(PUBLIC HEALTH SER%r ;ES <br /> ENVIRONMENTAL HEALTH DNISION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <br /> (209) 468-3420 j v b� <br /> 100-WUIIDILRLE PERMIT EXPIRES I TE1S FROY DATE ISSUED P'���I <br /> MwglBa IN Trb0olPl <br /> APPMATION IB HERE BY MAGE TO TME BAN JOADURN COUNTY FOR A►SOT TO CON6TRVCT AND/OR WXTALL THE WORK DECCF0EO.TIME APPMATION W MADE M CO&AKt RICE WRII SAN <br /> JOAOUM coUNTY DEVELOPMFNY TITU,CHAPTER 91-111 1 6.3 TME 9TANDARD9 Of WW JOACU N CO(hh rY PUBM REALTM SERVICES-OWUMMS10"AL IIEALTM OMSION. <br /> JOB ADDREBS/OR AAP,NR a� CITY J� � vMAEL MZPJMW# <br /> OWNER'S NAME �` ADDPEBs gROnE/ <br /> CONTRACTOR AOOAEBB UOI PHONE <br /> SUB CONTRACTOR ADOREBa �/ LIGy PHONE I <br /> l v I ! <br /> TYPE Of w[LIJeJmp- ❑ NEW WUJ_ ❑ AESLJACEtItEtft WELL Cl AIOAtroI.+G wgl i �oTNER r Iylpnl f�'"r�y�7 <br /> ❑ IAHTALLATRTN Q WEU.BYBTETI REPAIR ❑ CROSSCONNECT REPAIR ❑ -A➢OR EBT ION WE&# J <br /> ❑W—❑R4a N.P. DEPTH PJMP BET PT. FMOT WATER LEM O 1 <br /> rtTPE or PUMP1 <br /> ❑ o .OF 9EIPACE WELL Cl OEOPMTSKAL WELL P ❑ WIL scmNO D <br /> 3OEOTRUCTION; <br /> wA 1 a44fe "I <br /> IN YNO(O VOfT T W GOM TtR7Cl10N t/!C>rfCA Rt 1 A <br /> DINDU6TRPA<L ❑GRN BOTTOM DIA.OF WELL"CAVATTOM /7 I OIA OF CONOt1CTOR C'ABDq 0 <br /> AI <br /> ❑ OOMEsTICMVVATE O oRAVEL PACRIBttE TYPE of QA81N0/BT100"1C + OAA.OF MsET.I cA91Nti tom- D <br /> ❑ PUBLIC iMUNICIPAI ❑OIMN DEPTH OF OIDLFT BEAL APECfMATION �r R <br /> ❑ IPPIOATONfAG OTHER; `%%FifA 1 a01 OVT BFJL WR��ID^B Ys �y. OFOUT BRAND NAME r_ Q V� �JN. E <br /> ❑ MDMR'OWNO `' CONCRETE PEDEsTAL By OVILL c <br /> APPRO[.OPTW LOCfCI10 CI£BTER BOX/6TOve PIPE s <br /> PPOPOS4'D CONBTAYCTWRIOIOLU)-o 11ACTN00: MUD ROTARY AIR RDTARY AUQM_�_CABEl_OTHER <br /> I HEMBY CER"FV THAT t 1/AVE PREPARED TRBB APPLICATION AND THAT TIRE.YOPK WILL Of DOPE W ACCORDANCE VATM BAIA JOAOVaI COU(T7 OF01MANCID.STATE RAwt.ANO RMB ANO <br /> rt5OULAT10NS OF TWE BAN JOAOVIN COVNTY. NOME OWAIER OR UCETIRED AOENT'e 410NATURE CERTIFIES TIRE FOLLOWING='1 CERTIFY THAT M T"t PEPPORMANCE Of T/IE WOAR FOR WMIC14 <br /> TWIT PER MjV IB ISOU[O,I IwALL NOT EMPLOY PERIDNB BUBJEcT To W01RVL4Aws ComwentATIOM LAWS OF CALFQ~Ak.' coNTRACTOR'B MOM OR SUBCONtRACT1NO SIGNATURE CEFRIFIEB <br /> THE FOLLOWING: '1 CF7LTIFY TWAT M THE Pp60RMANCE OP TME WORK POR WHIL1I THIS PPRMIT Is ISSVED.1 WHAA.1 EAAPIOY PERPONB MURJECT TO WORIUWAN'S COMPWBATION LAWS OF <br /> CAUFORMA.' T='xrzw IN AOVANCI FOR ALL PIMM RD NPLOW/1004 AT 1*m1 A=-ands. COMPUTE I7A%MHG AT LORMEII AREA PROV10[O. <br /> Blor.sd)< <br /> ROT PLAN{Drs*.e.Be.M 6..1. ` b <br /> I. NAMES OP STREYFB OR"DADS REAREST TO OR BOUNOWO TIRE PROPERTY. A. LOCATION OF NOUBE SEWAGE DR9POBAL WTSTFM OR r"ORVBED <br /> i. OtfTLINE OF Tsm PRIOPERTY.amiNd dMENVONB ANO NORTH DIRECTION. EXPAUSLON OF SEWAGE DISPOSAL,ITBTEMB. <br /> ], bIMCNS10T1F,p OUTLINES AND tOCATION OF.LLL EX19TMO AND PF%7M W� t, IOC ATOM OF WELLS IA'fTNM RADIUS OF ONE ANNDIIED FIFTY FY. <br /> STMOCTUNES,INCLUOTNO COUIMD ARREAR BVCH AS PATIOS,DRIVEWAYS,AND WALKS. OM THE rROPERTT on AOJo1MFq PROPERTY. <br /> AIIPenL—Amp/Pd BT <br /> O'w w••vmI`.ST On. Har..r>.P I—BT 0— <br /> O.LA <br /> b+Inor�+n Ir�Pmllr.�BT <br /> ism <br /> ACCOUNTING ONLT- AIDI FACS <br /> PE coOEA FEE IMOD AMOUNT 1Rte'�TTUD C APR RLOHVED BY DATE P9MTaFDMCE REOUEST RLBRBa TNVOIC6 <br /> X51 D `lS? O �78 <br /> Pub.Heflkh SOM-En,11M 173(1/97) <br />