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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NOW-REFUMDAPLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> lCER1pYES in TTIpReNi) <br /> APER CATION 19 IRRE BY MADE TO THE PAN JOAQU/N COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE VMW DESCRRIED.TIDE APPLICATION IS MADE IN COMPLIANCE WRIT CAN <br /> JUAWN COUNTY DFVELCPMENT TITLE.CHAPTER 5-1116.3 ANDTHE STANDARDS OF PAN JOAOLN COUNT.Y.,FURX HF/1LTN SERMEeENVIR <br /> . ONMENTAL HEALTH OMBION./j <br /> "De ADORESSDN ARM I10 33 P.� W CITY �/ Q7GFS�O At PARCEL PRF/APNIF / A/� <br /> OWNER,NAME VAA/v£V AP61Q A... (- p V v P..., Z?Z-qyi/ <br /> coFGRACTOR �LV/�E� ADDRESS U cF !P1.I <br /> AVS CONTRACTOR UKQ <br /> �-T FT--'TL ADen UCO RIONE A <br /> EU <br /> TYPE OF WIPWIt. ❑ 0 NEW WELL AERACFWW WELL ❑MowyoRINQ vvtu F ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROBS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL/ J <br /> ❑N-13 Ru.o 01P.. DEPTH NMP SET FF. RMT WATER LEVEL O <br /> R YTE OF PUMW {-T <br /> OF-SERVICE WELL ❑OEOPHYSCAL WELL* U 901E SORMO S <br /> ❑DESTRUCTION: <br /> Int EMOEO VK TYPE W CONSTRUCIION SPECIFICATIONS A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑DOMESTICRRINN <br /> VATE ❑GRAVEL PACK/SIZE TYPF OF CASOMTFEIJPVC OIA.OF WELL CASO D <br /> ❑ {M <br /> PNJC WUNCRWO <br /> AL DRIVER DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑WMOATSON/AO ❑0THER GROUT SEAL WWALSED BY GROUT BRAND NAME £ <br /> ❑MONIToRINO ORO VT SEAL PUMPED:❑Yr ❑W CONCRETE PEOE9TAL SY O/OLLER:❑Ym ON, S <br /> APPROX.Dt"N LOCKING CHESTER SO%!STOVE PIPE S <br /> PROPOSED CONSTRUCTIOPIMMUSNO METHOD: MUO ROTARY AIR ROTARY AUOEN CAME OTHER- <br /> 1 M VBY CERTIFY THAT 1 NAVE PREPARED THIS AFRICATKTN AND TNAT THE WOM WXl R DONE N ACCORDANCE WFTN SAN JOAOUN COUNTY ORDINANCES.RATE LAWS,AND R1X£9 AND <br /> ROUATIONS OF THE SAN JOAOUN COUNTY.HON(OWNER OR LICENSED AOENT'S SIONATURE CERTEES IMF POLLOWN10:'1 CERTIFY THAT N F THE TINE PERFORMANCE OWOM FDR WMCH <br /> THIS PERMIT IS ISSUED.1 NIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPOISATON LAWS OF CALIFORNIA.*CONTRACTOR'S RARING OR 9USCONTR4LTIG SIGNATURE CERTIFAS <br /> THE FOLLOWING- ITT <br /> IPY TNAT N PEIECR MANCE TILE WOFW FOR WHICH THIS PFFOaT IS ISSUED,I SHALL EMPLOY PERSONS OUS.RCT TO WORT HAWS COMPENSATION LAWS OF <br /> CAIITOIOIIA.' T A ANT ARMIt C N 1SOW 1 AMCS POR ALL REOU/RO IMEPWIRONS-AT f2M SBS�.U".COMPLETE ORAWIFIO AT LOWER AREA PROVIDED, <br /> Com' <br /> SHP,.A% �!o TRIM T On. <br /> ROT RAN IAM I.B I M.Y N <br /> t.NAMES OF StREFTS ON ROADS NEAREST TO OR eOUMNTY <br /> OO THE PROPER . E. LOCATION OF HOUSE SFWAGE OMPOSAL SYSTEM OR PD/OSED <br /> PEOY <br /> E.OUTLINE OF THE PROR ,GIVING DIMENSIONS AND NOIRTN DIRECTION. VIPANSKM OF SEWAGE ORIPOSALTST <br /> SEMS. <br /> 3.LKLAFNNDFED OVTLNFS AND LOCATION OF ALL FXRITNO AND PROPOSED S.LOCATION OF WELLS WITFIN RADIUS OF ONE FRIFFOFRD I— <br /> NNOAREAS <br /> TT. s <br /> STRUCTURES, CLUOCOVERED ARE S SUCH AS PATIOS,DRIVEWAYS,AND WALXO. ON THE FPIOPERTY OR ADJOINING PROPERTY. <br /> .8 <br /> ILL <br /> V. <br /> MAY <br /> . ................ <br /> T31VlP Nx:chE Al'!E LiH:CIV�i1C? .. <br /> ..tet. <br /> DFP TMENT USE ONLY <br /> t✓VV ( �it.il� <br /> APPb.IMn A..yIM Iti <br /> D,.0 w..000A.n eT Gw. P,.Yo 1rr.P.oel.n ar D.+. <br /> O..IOO�rbn lnlp.elbn er or. <br /> a b - <br /> ACCOUNDNO ONLY: ADF FACE <br /> FE CODES FLEE INFO AA40AMT RTFATTTD C RCKFC H KFCIIVFb BY DATE POIROTI9SINCE REQUEST NUASSR INVOICE <br /> \ f <br /> Pub 4e9f[h$Sry-Emiro.173(1/9)7 <br />