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APPLICATION FOR WELLIPUMP PERMIT _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION D2 <br /> 304 EAST WEBER AVENUE, STOCKTON, CAC <br /> O _ i �9ac �.� <br /> (209) 468-3420 <br /> NOA REFUNDABLE PUMIT EXPIRE= 1 YEAR FROM DATE ISSUEQ <br /> 1Co"ists In TTip0minl <br /> APPLICAT"19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR M19TALL THE WOFK DESCRIBED TIt1S APPLICATIQit/9 WADE?i,COMPLIANCX VTTT31 SAN <br /> -OAOUTH COUNTY DEMO TCTLE.CHAPTER 9-1115 3 AND THE 9TANDAFOR OF SAN JOAQUIN COUNTY PVRLIC HEALTH SERVICfB Hi"RONIAWAL"EALTH ommom <br /> OB ADO SSIOR API/ c"Y_ �r���'`��' F PARCEL S12FJAPNI r <br /> l P <br /> OWNER 9 NAME J 4OOFEBM .r r .1 ..•+_ 4 PHONE l•C'S L� 1 ~ <br /> CONTRACTOR C�� 'b.�, .r�*c c K..._,,,t�.J�.+..► AOOnE9i.��„� - - �-`-' -- } E I .�r'Y S PHONE�P��rrl I 'z y <br />' y �;;.ci. v.... AOWME9M `� 1 UCj I �.0= PHONE jr �C y`f - <br /> 4US CONTRACTOR `a,. <br /> rrP[OF m&0a P• ❑ NEw wEu © regiXEMENT Wm 13 A.ONROmom Neu M ❑ OTHER <br /> ❑ MHITALIATION © wet 9YMTEM REPAIR ❑ Cnoes-cow*CT Mmmm ❑ VAPOR EXTRACTION Amu I 1 <br /> ❑Nw.❑P.-w H a DEFT"PUMP 9ET FT FlIW wATTR LEVEL. o <br /> TV"OF PUMP1 <br /> ❑ olFr40-9ETIRRCE wtt1 ❑ oEOF+ns1eAL WELL s soa.9olMl/w a <br /> ❑oEerw/cYloN• <br /> WOWED USE TYPrt OF W COMiriNcnom 9PECIrt cInaMM A <br /> • I�,L,4 w.t. <br /> C3 MIDUSTMLAL ❑ore,BOTTOM DCA.OF WELL EXCAVATION � DIA OF CONDUCTOR CASCNO Q <br /> Cl OOMESTWdPWVATE ®OX^vft PAOUSIZE VAu. .] TYPE OF CAWNW=EELApVC Q��+ �GM OIA,OF WELL CAS1lq �a - R <br /> ❑ pVB XAWFRCWAL ❑omvew OEFTN OF WIDUT SEAL SPECIFICATION �a� _t �•` R <br /> ❑ MMOATIONIAG ❑OTHER GROUT SEAL I ITTALLED BY�� <- C-t-- OROITr BRAND HAIJE r 11 E <br /> © Mowromma GFIOUT L AL PUMNFO- ®Y» CIN. CONCAETB PEDESTAL By OFYUtTh D Y. I�1 N. s <br /> APM03L OSO•THLOCXWO CHWO't BOXMfOVE PIPE S <br /> FROPOMg,COMMTLRICTLONIDF9LLIRO METHOD: MIJO ROTARY AHI ROTARY AUOEit� l- -- CAKE 04HER <br /> I HEqeoy CERTIFY THAT I NAVE PF%PAMM n"APRJCATIOM ANO THAT THE WORK WILL BE DONE M ACCOFOANCE V""SAN JOAOURC COV OFM'AFICE4 6rATE LAWS AND RULES AMU <br /> ' <br /> 1IEpVtAT'CONo OF THE SAN JOAOUMN COUWry HOME OWNER OR IJCENOED Aaffe"m4MAT[MME CERTB9E9 THE POtLov%% ' i COMFY THAT IN THE F9IFOFYAMCI<OF TME WOMB FOR WHICH <br /> HIS PERMIT Ili MOLFED 1 9HAL1 NOY 00"y FORCOM MnACT TD Vf0R=AAW9 C4Or MMAM9 UWJO OF CMOMOA.' CONrRACTOFrM H:iMW OR itK4CONTTtACTWG 9ITNATIM CERT*WO <br /> THE FOILOVrING '1 CERTIFY THAT W TH2 PEFPOPAWCE OF TH2 WOFM FOR vdmM TWO POV'0 W IOCUM I CHALL EL47LOY POICONO CUllieCT TO op'L COAAPi719A77ON LAVVSI OF <br /> tµA-0PoWA.- TN7 AMMANT MOOT CAL 24 got=I=AVVANCII FOR ALL ItZM==pOPGCTtONO Ar[SOq dC ZdXSL COUP""ORAW00 AT b"IER ARFA PPOVIOEO <br /> NO�d X !� TN. }7J.- r,i t'I (_a-t- -' ----D. <br /> J <br /> FLOT PLAN io.a-I.9.e&a <br /> T NAMES OF"RSFTO OR ROADO NZAF2OT TO OR BOUN02M THE PROPERTY L LOCATION OF 1 OIM 9EWAQE OeCPDOAL 9MIU4 OR PROrOOED <br /> 2 ou"iNE ROA TILE FRDPEIITIT OIVr/0 OMASHOONM MMD MOWN 0111ECTIOM E)WAN6IDH OF CVW^02 Wer OAA.QTIITtM. <br /> 0I1MEUWON110 OUrLpWG AMO UWATION OF ALL CXMM M ANO PFIOPOIEO R LOCATION OF VEL"WITHQI RAM M OF ONE HUNDOW FIFTY MT <br /> STR PCTUMIL NCLI/ORIO COV@®AMU WC"A&PATIOS.0F6VEW^Y9,ANO WALX& ON THE PROPEFRII OR ADJONI M PROFL3rrY <br /> U;t 10a-'C'� <br /> DVPwTMatT use OFILY <br /> a.~w......M.n Br O.I. Pram.w.*�tl By OM. <br /> D...nrefwwr I.n...CMan er D.I. <br /> a 21-5ZZs ?�. t - <br /> � <br /> ACCOLJIfriNO ONl7 IIID* FAC! <br /> ME COOEM FEE iRfO AMOUNT ROAMID C JGASN RECSVED BY DATE PUIMITlBFRVSCE REODUT MM MM INVOICE <br /> 3 .+ -+o aMh Hary =Zvern '� 471 <br />