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OPPLICATION FOR WELUPUMP PERM* <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> ROIFREFURDAREE PERMIT EXPIRES 1 YEAR FROM OATE ISSUED <br /> (CImpALI M TrbReltll <br /> APRICATION IB HEM BY MADE TO THE SAN JOAp➢N COI FOR A PERMIT TO CONSTHUCT ANOMR INSTALL THE WOHL MSCRISM.THIS APPLICATION IB MAGE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER1-1115.E AND THE STANDARDS OF SAN"AWN COUNTY PUBLIC HEALTH SERVICES.ENVmONMENTAL HEALTH GBAWN. <br /> JOB ADOHESIMOR APNI l-}nr,.n 1'1 1 (, OT - S �A I' <br /> �I 1��T `�� CITY /��^'j��/1rrp PARCEL 912EIAMe <br /> OVMER'S NAMEL)t I'Inn1 L—�4on 4fDY02f�F1 Yl� AWESS �Y?L.1- lT1 YY11 'LT �nmCn rwNEI l4�S�,S4.3-S�/� <br /> CONTRACTOREFz <br /> x AooREel)jgf� l,�11 ,�-=c_ �,AIc, AIn, �i NP RIONE II �`!IQ(:"91'C� <br /> RUB CONTRACTOR / �� ApOlEBB IJCTYMF/lY� <br /> — -�J'.'' O..c <br /> TYFE OF WFM,M)MP. ❑ NELN WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CMSSLONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> Cl Nw 13 R H.P. DEPTH PIMP SET—FT. FIRST WATER LEVEL 0 <br /> IT VPE OF MINIM <br /> Cl OUFOVGIOS ICE WELL ❑ GwFmY ICAL WELL/ x SOR BORINO I L <br /> B <br /> ❑omimucTION: <br /> INTENDED USE TYPE OF W" CONETRIICTION SPECIFICATION{ A <br /> ❑ INDUSTRIAL ❑OPEN ROTTOM DIA.OF WELL EXCAVATION DIA.OF COHWpTOR CASINO 0 <br /> ❑ MMESTICMIVATE Cl GRAVEL PACXISOE TYPE OF CASINCIMTEFL DIA.OF WELL CASINO 0 <br /> ❑ PUBLICSAUwwm. ❑URVEN DEPTH OF GROUF MR, SPECIFICATION R <br /> ❑ IPA*ATIONIAU ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ M WOWNO GROUT SEAL Mammo: ❑Yr ❑Na COMTETE PEDESTAL BY DRILLER:❑Yr ❑Ne 5 <br /> APRROX.OEPTH LOCKMO CHESTER BOXMOW PPE <br /> S <br /> MOMSFD COMSTl1UCTOMNRWMG METHOD: MM ROTARY AIR ROTARY AMER CABLE OTHER <br /> I HEREBY CERTIFY THAT t HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WIM BE DONE M ACCORDANCE WON SAN JOAOMN COUNTY ORDINANCES.STATE LAWS,ANO RULES AN; <br /> MOLXATMNS OF THE SAN JOAOUIN COUNTY. HOME OVMER OR LICENSED AOENT'R SIGNATURE CERTNES THE FOLLO`AINO:'1 CERTIFY THAT IN THE PERFORMANCE GF THE WORK FOR WHMN <br /> THIS MWIT IB ISSLED.I RIALL NOT EMROY PERSONS SUSJECT TO WORXMAN'S COMIIENIAMN LAWS OF CALFOR I&' CONTRACTOR'S MRNO OR BUBOORHIACTMB SI NATME CERTIFIER <br /> THE FOLLOWING: 'I CERTIFY THAT M THE MISFOPMANCE OF TETE MORN FOR WHICH THIS PERMR 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WOHLBMAM'S COM,dSATION LAWS OF <br /> CALIFORNIA.' THIS APAICANT MINT CALL 24 MOBS IN AOVAMCE MR ALL M M M I�NSRCTIONSSAAT 12INN 401- =. COMPETE DRAWING AT LOWER AREA RIOVOED. <br /> Slaved x 1 laO2L,,�t \il. uSS rift <br /> \ \ !tt <br /> ROT RAN(Or.b Se.lel BaNe 'to <br /> 1. NAMES OF STREETS OR ROADS HFAW TO OR SOVNDIIq THE PMPERTY. A. LOCATION OF MUSE SEWAGE OISPOSAL SYSTEM OR P MRD <br /> 2. OUTLINE OF THE FEROPERTY,OIVO/O 01MENVONS AND NORTH DIRECTION. EXPARSION OF SEWAGE DISPOSAL SYSTEMS. <br /> G. DIMENSIONED OUTLMFS AM LOCATION OF ALL EXISINO ANO PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNTIRM FIFTY FT. <br /> STIMICTMER.INCLMIM COVERED AREAS SIXTH AS PATIOS.DRVEWAYS.AND WALKS. ON THE PNOMRTY OR ADJOINING PIgFFRrY. <br /> O terra POb¢-d cSoi\ I�OfiOCE ._... �. <br /> [r JL}/1 yin OERARTMONT use ONLY /,!} <br /> AePlbEtbn Aave0te8 BY fes' "V - \ ON. Nr ` ` <br /> 0reur IrwPmlla.eT D.b wne Ir»P.eUm,Br DFI. <br /> Owvmlbn Irwpenbn Rv D.t <br /> ACCOUNTING ONLY: AID, FAC, <br /> FE CODES FEE INFO AMOUNT REMITTED CIE , ASN TRECERRID BY DATE 1`9IANTRFRVICE REOUEST.NWVM INVOICE <br /> Pub `Neatth Serv.-Enviro. 173(1/97) <br />