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APPLICATION FOR WELLIPUMP PEAR <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIOIE <br /> P.O. BOX 388. 304 EAST WEBER AVENW, STOCKTON. CA SMI- 8 <br /> (209) 488.3420 <br /> NOM-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED j <br /> (C&Iepl&t*in TTIpg4101 <br /> APPLICATION 18 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED.T14I8 APPLICATION IS MADE IN COMPLIANCE WITH SAN' <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 115.3 AND TH STANDARDS OF GAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OMWON. <br /> JOB ADDRESSM APNI ( CRY_5 R f 1�('i PARCEL BI2ElAPNI <br /> OWNER'S NAME POf <br /> ADORES* 1• • +J ox <br /> � � PHONE AZ 7)4L:S34LL <br /> i CONTRACTORA4!&11(kf) (Stef ii�.'11�d17(% ADDRESS/�,4• /,,b 5')q. LIC/ PHZE Lo "I <br /> SUB CONTRACTOR M 4i by 1 I Q A 1 1I II j4 ADDRESS 1� t1 i� LIC/ A PHONE f <br /> IM OF ❑ NEW WELL 0 REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR088•CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 9 J <br /> E 11 N.w 0 Repel, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL d, <br /> ;RYPE OF PUMP) <br /> ❑ OUT-0F-SERVICE WELL ❑ OEOPHV6ICAL WEU.I BOIL GOWNO <br /> LJ DESTRUCTION: <br /> F <br /> INTENDED use TYPE OF WELL CONSTRUCTION SPECIFIC TION& 11 A; <br /> ,p INDUSTRIAL ❑OPEN BOTTOM OVA.OF WELL EXCAVATION C� __ _• DIA.OF CONDUCTOR CASINO D� <br /> �❑ DOMESTICIPRIVATE ❑GRAVEL PACK161ZE <br /> TYPE Of CASIN0/BTEEUPVC DIA,OF WELL CAGING O <br /> U PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> 0 IRRIOATIONIAO 13 OTHER GROUT SEAL TNSTALLEO BY GROUT BRAND NAME K,t4 10.1 t f <br /> AMONITORING GROUT BEAL PUMPED: ❑Y•• 0 No CONCRETE PEDESTAL BY DRILLER:❑Y•• 040S <br /> tAPtNLOX.DEPTH .✓� -- LOCKING C14EGTER BOXIBTOVE PIPE 51 i{, <br /> PROPOSED CON*TRUCTIONIDRILUNO METHOD: MUD ROTARY AIR ROTARY AUOER�R CABLE OTHER <br /> rI HE9ESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AMC <br /> REGULATIONS OF THE GAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PfRFdRMANCE OF THE WORIC FOR WIWt <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORXGMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'8 HIRING OR 81.111,CONTRACTING SIGNATURE CERTIFTfI <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS DI <br /> CAUFOIWIA.' THE APPLICANT MUST CALL 24 HOUR*IN ADV&_— <br /> FOR ALL REQUIRED INSPECTION&AT 1208)440.142!. COMPLETE DRAWING AT LOWER AREA PROVIDEDSlq�XThl. (Fe o.:. <br /> G' O <br /> ' PLOT PLAN ro..y+=to Gwl•I to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION DF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE Of THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL RYGTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXtSTINO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ADVANCED GEOENVIRONMENTAL INC 4 5 8 <br /> OF NORTHERN CALIFORNIA <br /> 1803 W MARCH LANE STE A (209) 956-0264 <br /> STOCKTON, CA 95207-5414 1-35 <br /> 1s9� Lz,� <br /> PAY /TO TH1 — P43 - � I $ORDEROF_ _J <br /> 5� <br /> �00 L L A R S <br /> u� Bank of America <br /> MwCh no HimCh 4139 <br /> 1546 Si.Marks PI91a <br /> Slockton,GA 95207 (209) 546-0230 <br /> , <br /> FOR �i ✓ v—�_ _ i's <br /> 100004 Salim 1: i 2 L000 3 581: L L 3 9 7- L S SO Sit" <br /> M 7Nr nt0c...Rlli^.:v 7,I V. f!/ll.�,i.�P4,1 (T wR.... ff._s ..Mw"TAP-w-a_"ilM5%TZnlftiwnr a"!.Rf9,� n: riI1N.G'.1'hJ":a tR, "11MV,ywRI"'-nr m:"fttr E:9Ifi-•:s. <br />