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APPLICATION FOR WELLIPUMP PERMIT :sFrTum 6, <br /> SAN&OUIN COUN-r( PUBLIC HEALTH S"wS p�sITC <br /> NVIRONMENTAL,HEALT.H DIVISION �' NJ Oi/( l�py <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 1199 �doo3([`t/,)�) (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _5L�,�y <br /> (Clmplftf In Trplkst.) u <br /> APVUCATION IS HERE BY MADE TO THE SAN JOAMIN COUNTY FOR-A PERMIT TO CONSTRUCT AMM11INSTALL THE WORK DE6CNBED.Title APPUCATION IS MADE IN CSIUbdANCE WITH SAN <br /> JOAOUI OUN DE aOOPMENT THLE.CHAFFER 8-1116.0 ANO THE STANDARDS OF SAN JOAGUIN COUNTY PUBUC/HEALTH NERVI ENVIRONMENTAL HEALTH IXVIp <br /> j1yftLVFF OT / / -b „• >0Nr t.\ u) Cm, SW • jyT PARCEL BIZE/APNI <br /> ON AGGRESSION A�PNE 1(�l'xJ R+ (�O1V la..n+ (s Z) <br /> /9�b uu.e� t�.e 11 /1 Fr. <br /> SIyy���==•.((((�'^if DC C.)MNL.+9�� <NQ.✓�S R' ADO � 9S�G PHONE!UO-LSI-S!!JO <br /> OWNER'S NAM G f ~ I <br /> Le�INs Fitacx� LI eel9co t-bwe�LST• PHDNE3t�546 96oz <br /> CONTRACTOR •/'�• �,E,�j/Ey. f W <br /> SUBCONTRACTOR /TR� yr„ r1�. ADOPEse �- .4t � CR 9�OS ucrCS7-S/9,76PPFFONE.?07-/i�'6.S-� <br /> IYPE OF WELLJPUMP; I1W NEW WELL ❑ REPLACEMENT WELL 101 tO MONITONNG WELL F ❑ OTHER <br /> - <br /> 0 <br /> ❑ MBTALLATMH ❑ WELL SYSTEM REPAIR ❑ CROBfrCOHNECTT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> NIA ❑NeW❑RWPT <br /> .4 N.P. DEH PUMP SE N/A FT- FIRST WATER LEVEL O <br /> (TYPE OF PUMPI ❑ OUT-0E-6ERVIOE WELL ❑ GEOPN ICAL WELL/ ❑ sok BONNG e <br /> ❑DESTRUCTION: <br /> A <br /> INTEHOEO USE TYPE OF WE31 DIA.OF WELLS EXCAVATION <br /> ❑ INDUSTRIAL 1❑1�AAOPENBOTTOM DIA.OF WELL E%LAVATION �O�Y ��• CIA.OF CONDUCTOR CASING /LJ/i4 0 <br /> ❑ DOMESTICIPNVATE Id GRAVEL PACKlSRE & TYPE OF CASINO/STEEL CSP II YO Py_ DIA OF WELL CASING Y• D <br /> ❑ PURUCMUMCIPAL ❑DRIVEN OEM”OF GROUT SEAL SOV SPECIFMATON 1 N <br /> ❑ IRNGATION/AG ❑OTHER GROUT SEAL INSTALLED BY ri Ike r GROUT BRAND NAME A/PR G Ce YAL E N� E <br /> ® MONITORING GROUT SEAL PGMPEO: ®Y•• ❑Nv CONCRETE PEDESTAL BY OPJLLER:®Yr ❑Ne s <br /> QO LOCKING CHESTER BOX/STOVE RPE)IPS s <br /> APPROX.DEPTH_ U <br /> PROPOSED CONSTRtq EON/DNWNO METHOD: MUD ROTARY <br /> MR ROTARY AUGER_CABLE OTHER <br /> TIIAT I IOR(WILL BE DONE IN ACCORDANCE VATH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> 1 NEPEBV CERTIFY IAVE PREPARED THIS APPLICATION ANO THAT THE W <br /> REGUTATION9 OF THE BAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEPTORMANCE OF THE WOR(FOR WHICH <br /> TI119 PERMIT IS ISSUED.I S14ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN"COMPENSATION LAWS OF CALIFORNIA' CONTMLTOR'B HIRING OR 6UBLONTRAI CO PESIGN ATTO CERTIFIES <br /> THE HIS TICTIMM 10 <br /> ED.I SHALL <br /> Y PENSIONS SUILIECT TO WORKMAN <br /> CAUFORNIA�N THE AI CERTIFY PPLICANTTHAT IN THE FERIMMANCE OF THE MUST CALL 11 HOURS IN ADVANCE FOIILRALL RE URETIFOR WHICH T(I1N3/PECTW N/AT911�144",,MnMCOMPLETE ORAWINO AT LOVER AREA fTiONDEO�SATION LAWS OF <br /> on. <br /> 9(,j x <br /> / MIT PLAN (0,—Ie 6c Vel 6a•I. -to <br /> 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On i`1tOro6ED <br /> I. NAMES OF STREETS On POISON NEAREST TO OR BOUNCING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEM9. _ <br /> 2. OWLME OF THE PROPERTY.GIVING DIMENSIONS ANO NORTH DInECTION. S. LOCATION OF WELLS WITHIN RADIUS OF ONE NUNOREO FIFTY FT. <br /> LL <br /> 3, DIMENSIONED OUTUNE6 AND LOCATION OF AEXISTING AND PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. <br /> /� Rp �f�a abed. <br /> � ocaBQ'— a � I1-714 <br /> DEPARTMENT USE ONLY 2-, <br /> CI <br /> AOPIIe.11en Aevrgled BY <br /> p.0 Pane Imv.vtlen SY Da. <br /> Oravl lnepallm <br /> a'- <br /> DIR. <br /> De.N�rlen In.Peclbn <br /> by .J"'� <br /> t 11�R <br /> cemm�A.: 7R' <br /> COS zt 11 <br /> -a/ <br /> ACCOVNTiNO ONLY: AIDI FAC) <br /> PE CODES FEE INFO AMOUNT Rm CHECKIMASH RECEIVED NY DATE PEVAITMERVICB REOUTAT NUMBER INVOICE <br /> Pub.Health SON.-Enviro.173(1197) <br />