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OLICATION FOR WELLIPUMP PERMIT QAJ ��(-e � <br /> ( SAN JOAQUIN COUNTY PUBLIC HEALTH SER 'ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <br /> (209)468-3420 IL <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICempl/ti In TFIp9E/t/I " <br /> APPUCATION IS HERE BY MADE TO THE BM JOAUUIN COUNTY FOR PERMIT TO COSUNUCT ANDIOR INSTALL THE WORK DESCRIBED.TINS AFMICATION IB MADE IN COMPLIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOPME/N�T TRIE:CCHAPTER 0-1115.3 AND T..HHEE STMOA �-OAMISS SOF SAN J0AWM COUNTY R/SLICHEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. p <br /> JOB ADORE63lOR AR!/ VO W I64 /)u DRY "a k-,-„lam.,_ PARCEL BRE /,o// <br /> IAFNI(CA7-- 7 <br /> ADDRESSFHD <br /> '!1`^^ ""«-” - &02' � -9z o o <br /> OWNER'S NAME - //•1�� <br /> CONTRACTORI.-K <br /> SUB CONTACTOR• ✓`^•�-�^ 1 _ • ADdtESB ,(,f,K.Y1VVV I---"7 H LICI . RIORE 1" C <br /> Cl OTHER <br /> TYPE OF WELVPVMP. ® NEW WELL ❑ RFPLACEMENT WELL ❑ MONITOMM WELL/ (.Q <br /> ^ [3MsTALLATION ❑ WELL SYSTEM REPAIR ❑ CRONSCONNECT REPAIR R VAPOR EXTRACTION WELL/ Ce <br /> N//Y ❑N,,,,pR, W H.P. DEPHPUMP6ET��R. ReTWATEREVEI O <br /> (TYPE OF MMPI ❑ BOIL BORING S <br /> ❑ OVT-0FSERVICE WELL ❑ GEOPHYSICAL WELL/ <br /> ❑oceTpuc*wN, <br /> A <br /> INTENOED USE TYPE OF WELL CONSTP TION s'c-IICATIOHI <br /> ❑ INDUb'TmAI ❑OPEN BOTTOM DIA.Of WELL EXCAVATIONT/yy,� N DIA.OF CONDUCTOR CASINO N O <br /> ❑ DOMESTICRRVATE ❑ORAVEL PAC t PPa TYPEOFCASINO/STEEE/PVC Wr— S pA OF WELL CASING G <br /> ❑ pUBUC/MVm mI ❑DRIVEN DEPTH OF GROUT SEAL 6F SPECIFTCAmm N <br /> ❑ IPRIGATIONIAG - ❑OTHER GMUT tIT SmNaA,,D By &,6 rO,i6 ORDUT BMNO NAME '^,[Lei On <br /> MONITOmNO/� I'dC F(jh GROUT SEAL RIMffD: ®Yr [IN. CONCRETE PEDESTAL OV ONLLEII❑Y« ®Ne S <br /> 30/ <br /> APPROX.DERN LOCKING CHESTER 90XFSTOVE RPE ✓DS T <br /> �`— <br /> moMsM CONSTRIICRONtDRIMINO METHOD: MUD ROTARY AIR IIOTARY AUGER_CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIN APPLICATION MO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BM"AMIN COUNTY ONOINANCEC STATE LAWS,AND RULES AND <br /> REOl1UTION8 Of THE BAN JOAOUIN COUNTY. NOME OWNER OR LICENSED ANENT-2 SIGNATURE CERTHIES THE FOLLOWING:'I CERNFY THAT M THE PERFORMANCE OF THE WOR(FOR WINCH <br /> THIS PERMIT IB ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORIVAAN'S COMPENSATION UWN OF CALIFORINA' CONTRACTOR'S HIRHO OR WU ONTRACTIHG SIGNATURE CERTIRES <br /> THE FOLLOWING: -I CENTIFY THAT BN TILE PERFORMANCE OF THE WONT FOR WHICH TIRE PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORMAN'S COMPENSATION UWe OF <br /> CALIFORNIA.' THE APRICMT MUST CALL 24 HOW IN A <br /> DV <br /> A <br /> N <br /> C <br /> E FOR ALL REGNIRM NNR,SCTN)R*AT RDSI 4"i =. COMPLETE OMVANO AT LOWER AREA PROVIDED. <br /> nam X��L <br /> � TSU. �/PC/SPOT �F r _GnA J�a.G��,T_ <br /> MOT PUN(0,-1."M-1 Bed. 'I. <br /> f. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TILE PROPERTY. 4, LOCATION OF HOUSE SEWAGE UIBFOSAL SYSTEM OR PROMSED <br /> E. OUTUNE OF THE RIDPENTY.GANG DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE DISPOSAL S OF ON. <br /> ]. DIMENSIONED OUTLINES AND LOCATION OF AL EXISTING AND PROPOSED R LOCATION OF WELLS WITHIN RADIUS OF ONE NUNORED fIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALK8. Off THE PROPERTY OR ADJOINNKI PROPERTY. <br /> SVAtw� -o05 ...a.....; ....$.KE- Cx�3 SvEOly. <br /> SVAI VJC -Do y oo yS— <br /> M �t <br /> SvrAW 0/y a DO...>s'.. <br /> V6fiCo $v MIN 0/5' 009 <br /> Dsvw�w Oi(o of 0 ' <br /> /I OVMTMENT USE OMIY G fro /�y/�� /y��yy/( <br /> Aeplenbn Aaaeetd BT T—`Y[/L/I�'"rOwS...`� I��` l O/ Nr V�✓V / <br /> O..o1 Ivo«Len Br Gu. PARS MrP«Ileo eY Om <br /> O.+mvt4n IneP.SSen BY Ons <br /> Cemmat.: <br /> ACCOUNTING OHLY: ADI FACT <br /> R CODES FEE INFO AMOUNT REMITTED <br /> MOVED BY OATE FFIRBTRERVICE REOUFIT NUMMEL INVOICE <br /> o ul 02 S-z8 D 50 <br /> Pub.Health Sew.•Enviro.173(1/976 <br />