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APPLICATION FOR WELLIPUMP PERMIR aced <br /> Q <br /> • SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES Y� <br /> ENVIRONMENTAL HEALTH DIVISION ^' <br /> P,O. BOX 388, 304 EAST VVEBER AVENUE, STOCKTON;CA 95201388 1 <br /> 12091409-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICBmp1818 In TdplkEl81 t <br /> APELICATION IB HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/On INSTALL THE MW DEBCnmFb.THIS AP'LI TION IB MADE IN COMPLIANCE WRH BAN <br /> JOAOUIN COUNTY DEVELOPMENT TILE,CHAPTER 9.1115.3 AND THFI STANDARDS OF BAN JOAQUIN COON PUBLIC HEALTH SERVICES,ENVI NMEMAL HEALTH DIVIRION. <br /> �F� 1X- ^' /S <br /> JOB ADORF89MR AM& O C , �`/L C�HY�/� L/ 1 L� PARCEL SIZE/AMP <br /> OWNER'8 NAME I ✓ Q I F 1 ADDREBSLLb' I RHONE I ( b <br /> 'fL L�e/r1A3P vn� cl D' 1r'�1_ arnr � fl 1 <br /> CONTRACTOR 1 bDREBBI r1,�/� TO 1 L RHONE_ <br /> Bun CONTRACTOR Fye _ADDRESS 1 0� wl'�'1'L 1 "— ' DC'IF 2�337,tP P�HfOcN1E 0 <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL Iq MONITORING WEII I OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR F T <br /> ❑ <br /> N.❑R.P.II H.P. DEPTH PUMP SET_". FIRST WATER LEVEL <br /> HYPE OF PUMP) <br /> 2 4 N)Q4LQPM�N n 'I ❑ OUT-OF SERVICE WELL ❑ EOPHYSICAL WELLI_� El NOT BORING B <br /> �DEBTRUCTION "1) A <br /> INTENDED UBE YPE OF WELL CONSTRICTION SPECIFICATION& A <br /> 11 INDUSTRIAL OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 <br /> ❑ DOMEBTIC/PFBVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELIPVC DIA.OF WELL CARING 0 <br /> ❑ PUBLICWUNICIPAL ❑DRIVEN DEPTH OF ONOUT BEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING OROUT BEAL PIMPED: Ely. ❑N. CONCRETE PEDESTAL BY DRILLER:❑Y.. ❑N. S <br /> A"OX.DEITN LOCKING CHESTER BOX/STOVE PPE S <br /> RROMEEO CONSTTUCEION/d11LDNG METHOD: MUD NOTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS AM4,CATIUN AND THAT THE WORK WBLL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE,.STATE LAWS.All RULER AND <br /> NODI ATIONR OF THE BAN JOAQUIN COUNTY. HOME O%VNM On LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN TNF PERFORMANCE OF THE MW FOR WHICH <br /> 71119 MMUT IB ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATOR LAWS OF CALIFORNIA.' COMPACTOR'S HIMNO OR BURLONTRACTINO SIONATUnE CEMIFIES <br /> TIIF FOLLOWING: -I CERTIFY THAT IN TIIF PERFORMANCE OF THE WOO(FOR WHICH THIS PERMIT 18 U)SUED,1 BIIALL EMKOY PERSONS SUBJECT 10 WORRMAN'B COMPENBATION LAWS OF <br /> 601 MIA.' THE APPJ N11/�B�VST LL 24 C 1 ADVANCE)R ALL INBP MMA It 12MI 44NI A21. COMPLETE ORAMNO AT LOWER AMA <br /> �PRROVIDED..J /j <br /> �'4 P C COS�AY/ D.I.60/l-I i <br /> Fmeon 0 04724 <br /> ASSOCIATES 1I210 <br /> 1433 N. MARKET BLVD. <br /> SACRAMENTO,CALIFORNIA 95834 1 1 <br /> lJ JUNE 19 LLJ 97 <br /> PAYTOT°F ****SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION***************a 60.00 <br /> OILUF,R OF <br /> SIXTY AND 00/100---------------L)AYMEN'T <br /> E-rrcTl 'S----------------------------------------DOLLARS <br /> FEB - 51998 IGH ATURES RE IRED I OVER $5000.00 <br /> BANK OF CALIFORNIA SAN JOAG+UIN wuNTI' <br /> San Mateo Office, San Mateo,CA 94403 FUOL10'HEq�TH S tl <br /> CES <br /> ENVIRONARENT'AL f,EAL H 01VISI00 <br /> _�`A)V-o�sasy <br /> X02 <br />