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LICATFOR WELL/PUMP PERMIT <br /> ON <br /> SAN'S QUIIN CIOUNTY PUBLIC HEALTH SER FILE COPY <br /> ENVIRONMENTAL HEALTH DIVISION +r <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> / (209) 468-3420 <br /> yIk NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUER I �r{ c� tt- <br /> t T (Complete In TrbfwEt l <br /> APPLICATION IS IIERE BY MADE TO THE SAN JOAOUIN COUNTY FOR-A PERMIT TO CONSTRUCT ANOMR INSTALL THE WON(DES JUSED.TARS APPLICATION IS MADE IN COMPLIANCE WTTN SAN <br /> JOAQUIN COUNTY DEVELOPGMENT TTIE.CNAF TER B- 115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY FURUC HEALTH SERNCI C.ENVIRONMENTAL HEALTH DM61pN. 6- <br /> JOB ADOPES9/OR APNI V l / e ' /2�) ����J/T CITY/ 9R2t/ <br /> /PARCEL SIZF/ARII -'ID AC <br /> OWNER'S NAME n/ `� '�"'-�'" ADUMIH �u �-� <br /> CONTRACTOR ✓� ADDRESS / 777UCJJJI`+ �+—PNOIIHe/ /J Q�/y��yZ_ <br /> N,.Q (•t/ ADDRESS Y /�AI�S�F.W/LGL- <br /> PHONE <br /> AVO CONTRACTOR 11qq <br /> TYPE OF WELUPIMP. RLE NEW WELL ❑ ME CEMENT WELL ❑ MONROR M WELL I ❑ OTHER ((11 <br /> ❑ BWTALLATMN ❑ WELL SYSTEM REPAIR ❑ CROBSCONNECT REPAIR ® VAPOR EXTRACTION WELL I�2 C C hLCDP11 J <br /> NSA ❑Ne.Y❑R P ' N.P. OEM"PUMP SET__T. FIRST WATER LEVEL <br /> (7Y OF PUMP( ❑❑ -0SOIL PORING a <br /> OVTF6ERVICE WELL ❑ RI <br /> OEOYMCAL / <br /> WELL <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION. A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION -@ TY N CIA.OF CONDUCTOR CASINO. N 0 <br /> ❑ DOMESTMCPRIVATE ❑GRAVEL PAC f Pea TYPEOFCAMNGATEEl/PVC We /s DIA.OFWELLCASn10 _ • C II 0 <br /> ❑ PUem"UNIOmAL ❑DISVEN OEM"OF SWIFT SEAL ((11 �� 6/ / / SPECIFICATION 1 / / /� R <br /> q❑1 IRRIGATION/A0 ,,/ /�❑OTHER GROUT SEAL INSTALLED aY V1tb SOH.H2LleL^ GROUT BRAND NAME '�,]�+Gn r-p 2m fONi IG E <br /> yq MOMTONNO/LO�T'a CI(yY.p GROUT SEAL PUMPED: ®Yr ❑Ne CONCfIETF PEDESTAL BY pNLLER:❑Yw ®Ne S <br /> APPROX,DEPTH 1 O0 LOC%ING CHESTER BO%/STOVE POEM PS s <br /> PROPOSED CONSTRUCTIOWDR WHO METHOD: MUO ROTAnY AIR ROTARY AUGER__CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED TWO APFUCATION AND THAT THE WO HC W BE DONE IN ACCORDANCE MATH SAN JOAQUIN COUNTY ORDINANCES.STATE UWS,AND RULES AND <br /> M OUTATIONS Of THE SAN"AMIN COUNTY. HOME OWNER on LICENSED AOENT'8 MHATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK POR WHICH <br /> THIS PERMIT IS ISSUED.1 SIIALL NOT EMPLOY SKMN8 SUBJECT TO WORIULAN'S COMP RATION LAWS OF CAUFORMA- CONTRACTOR'S HIRING OR WU ONTRACTIHO MNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK TUR WWCH TMS PERMIT IS ISSUED.I SHALL EMPLOY FERBONB SUBJECT TO WORIONAN'S COMPENSATION IAWS OF <br /> CMIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN A ANCE FOR ALL RMURM IIN�SPE/CTHNHI AT 1205144NI COMPLETE O WUgo AT UO R AREA FRONDED. <br /> \ . TL <br /> � 4,4 rDn \�1E1 <br /> 9Iy <br /> 0.0T PLAN Drnv Ie BeY.I aeW 1. <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUN XW THE PROPERTY. A. LOCATION OF HOUSE E DISFUWAGE DIBFOSAL SYSTEM OR PLDroSEO <br /> 2. OUTUNE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE TWH A SOF ON <br /> T. D"ENS"Wo OUTLINES AND LOCATION OF ALL EXISTINO AND P MSEO S. LOCATION OF WELLS NRTNM RADIVS OF ONE HUNOIRED fIFTY fT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,OFIVE01AY9.AND WA R. ON THE PROPERTY On AOJOMRq PiDPEiiTY. <br /> MP0)4S <br /> DEPARTMENT WE ONLY <br /> Applk.tk Ae..A-f By <br /> OrM I/eemllan BY <br /> Om P.OF In.PRroOen Br ml. <br /> DeHN<IaR M.P.oI�Y �UE �� iciANY `/"/�(, <br /> ACCOUNTING ONLY: ADD FACS <br /> PE COO" FEE two AMOUNT REMITTED CHECIV!CASH RECBVEDST DATE P[RMITISFANCE REQUEST NLMSBI INVOICE <br /> Zqo VUl 0 / S-ss <br /> b D <br /> Pub.Health SeN.-Enviro.173(1197) <br />