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P � , . • � tri <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION D ���� <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 5202(( )) H � 199 <br /> (209) 468-3420 �V� <br /> NOX-REFUNDARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAOUtN COUNTY FOR A PER MIT TO CONSTRUCT AND/ORP INSTALL THE WORK OESC%BED.T1118 APPLICATION'S MAOE IN COMFLMNCE WOII SAN <br /> JOAOUIN COUNTY DEVELO MtE.CHAPTER 9.1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OMBION. <br /> CTI �FL�E-T `�- PARCEL 912EJAPN/ <br /> JOB AOORE99R]R APNI L �a..L ✓.^ � _ r <br /> ADOIIESS <br /> OWNER'S NAME - -a t...J ruit i.�a. � �p `aY:•,H_� <br /> _ - . L UC:-- <br /> 2 <br /> C:- 1:.-�ai3Y3 r1MNEn Lot-i' 2S'2-'�ILv <br /> CONTRACTOR L..�,ru".-nz.-_t c_\ �,-�:"a..fL e+�> - AOpR88 <br /> 4 <br /> 1 .I lv..... AD S{ ;\I. _ :i.. 1`i UCl 11CC�`\ MONEI '�lCil ?i`/' . <br /> PVB COMMCTOR W - fY i I <br /> TYPE OF WfUJMUMP. ❑ NEW WELL ❑ REPPACEMENT WELL LJ MONFTO%NO WELL I 41 ❑ OTHER <br /> ❑ NSTMIATMN ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPoR EXTRACTMN WELL I <br /> ❑N. R.P.Y H.P. <br /> DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> (TYPE OF RIM% L3 BOIL wmNO S <br /> ❑ OVT-0F{ERVICE WELL ❑ DEOPHVVICAL WELL <br /> ❑OEBTIPIICTMN: <br /> A <br /> INTENDED UtE TYPE OF WELL COM{TRIFTION SPECIRCATIOM{ <br /> ❑ INDUSTPoAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �s OIA.OFCONOMTORCAMNO <br /> �K ti _ <br /> ❑ OOMEBTICANOVATE ® VEL <br /> OMPACK/BTZE N'.PM -A INOTYPE OF CAB /BTEEI/PVDIA.OF WELL CASINO T. O <br /> LC� Pa'� - <br /> ❑ PVBUCMVNDmAI ❑DRIVEN DEPTH OF GROUT BEAL A'/ SPECIFICATION <br /> ❑ IRPoGATMHIAG ❑OTHER GMUF VEAL INSTALLED SY'� i:.w.L �.('1 OROUT SRANO NAME Y:.�F I:'^� .�'u E <br /> © MONROPoNO GROUT VEAL PUMPED: ®Yr ❑NB CONCRETEMMITALSYDPoLLER:❑Yr ®N. 5 <br /> APFHOx.OFRH <br /> LOCKING CHESTER SOxinovE RPE t <br /> PROPOSED CO"G`FRUCIMX,,,UM METHOD: MUD MTAIIY Am ROTMY AMER_/ CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE REPAREO TM/APPLICAIMN ANO THAT THE WORK WRL BE DONE M ACCORDANCE YATH BAN JOAOVIN COUNTY ORDINANCES.STATE LAWS,AND ROLLS AHO <br /> MOIMTONS OF THE SAN JOACVIN COUNTY. ROME OWNER OR LICENSED AGENT'S BMNATURE CEMPNES THE FOLLOWIPOG!'t CERTIFY THAT M THE KFMFPAANCE OF THE WORK FOR WHICH <br /> THIS PEANUT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TD WORKMAN{CCMFENSAIMN LAWS OF CAIIFORMA.' CORNRACTOR'S 111RIHD OR SUSCONTTNCTNFO SMHATURE CERTIFIES <br /> THE FOLLOW : -I CERTNY THAT N PFOMAANC <br /> THE PEE OF THE WORK FOR WHICH THIS PEFAM IB ISSUED.I SHALL EMROY RReOM SUBJECT TO W011OMAM'{COMPEMSATMN LAWS Of <br /> FOLLOWING: <br /> CAUVORMA:nTHE APPLICANT MUST CALL N HOUR{N AWANCE FM ALL REDLINED NSFEC/MNS AT 1108)Ar-E'{fS- COMFLETE OFAWR O AT LOWER AREA RPOVMED. <br /> '\ 1 mm. <'j-" <br /> ROT FUN ON.t.S..IN B.N. 'Is <br /> R. LOCATION OF MUSE <br /> EWA SEWAGE ALF I SYSTEM OR PROroeED <br /> 1. NAMES OF STREETS OR ROADS NUREST TO OR ANN) IPM THE PROPERTY. FXPAMSON OF SEWAGE DISPOSAL h'BTFM{. <br /> 1. OIRINE OF INE RIDPEIITY.OMM DIMEMBIDPIS AND NORTH OMECTION. S. LOCATDN OF VMLLB VIITRIIN RApUB OF ONE HUNDRED FRT/FT. <br /> O. NMENBMHED ovTLw.S ANO LOCATPDN OF ALL EXISTINU AND R SEO ON THE RIOPEIKTY ORI""ROM PIPOPERTY. <br /> STRUCTURES,BICLVDRID COVET®AREAS SIFCN M PATIOS,DRIVEWAYS, <br /> A�N�O WALKS' <br /> OITMTMENT USE ONLY <br /> APPA..tbn A.aaPIaO BY On. Nr <br /> O..N M,.P..t1en SY Ort. Pvn.tir. 1t BY O.I. <br /> Ort. <br /> GSlnstlen Imm«tlen BY <br /> Demrnw.H: O / D ZJs Z2s ?�. t <br /> ZI 1,16L W1102. <br /> ACCOUNTING ONLY: MDI FACT <br /> 77 <br /> PE CODES FEE INFO AMOUNT ADM"M CHECK RASH RECOVED BY DATE % TRERVICE REQUEST NUMNER INVOICE <br /> FFf O 91F2, <br /> I <br /> Puh 4eRlth Serv.-:11Viro.173 11;971 - <br />