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` C U r,l(i•f�l l�. <br /> APPLICATION FOR WELL/PUMP 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 /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> MempIEtE IS TR4ReEtal <br /> APPLICATION 19 HERE BY MADE TO THE BAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOK INSTALL THE WOR(DESCRIBED.7109 AF'PLICATKTN 18 MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TFTLE,CHAPTER 9-1115; T STAND S SAN JOAOUIN CO ft/8LC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. <br /> 1 r _ (/( <br /> JOB ADORESSMA APHI t>—?-3(:>2—?3 ✓ n ( CEIY PARCEL BIZEJAPNI Z®//7CNQC <br /> OW/IEp'S NAME (`n t^L G NSPV� ADINE9B Rl <br /> Ad", :Ip/ <br /> COMRAc70R Se LS Dr rK AoopESB//� LK6�PLZ PEIONEIy��7�. \ <br /> SUR CONTRACTOR ADOM99 LCI RHONE <br /> TVPE OF WEUJPUMP;>it—WELL ❑REPLACEMENT WELL ❑MONTORNq WELL I ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR GTRACTON WELL ITJ <br /> ❑H.w❑pi-. H.P. DEPTH RUMP SET_FT. FIRST WATER LEVEL O -� <br /> FT VFf of PUMP) <br /> ❑OUT-OF-BEINICE WELL ❑GEORRY9ICAL WELL a ❑ BOK BORING B <br /> ❑ <br /> DESTRUCTION- <br /> INTENDED USE TYPE O ELL CONSTRUCTION SPECIFICATIONS A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> lirIMMESTICIPPIVATE WRAVEL PACK/SIZE TYPE OF CASINGMT EEtii'vC OIA.OF WELL CASINO O <br /> ❑PUBLICNMUNICIPAL ❑DRIVEN DEPTH OF OROUT BEAU SPECIFICATION B , <br /> XRSTIOAMN/AG ❑OTHER GROUT SEAL 049TALLED BY Inase I GROUT BRAND NAME E <br /> ❑MONITORING aRDUT REAL PUMPED: I. [IN. CONCRETE PEDESTAL B DRILLER:❑Y-k- S <br /> AMROX.DETH �2 2-0 ' LOCKING CHESIER BOXIBTOVE PIPE 5 <br /> PROPOSED CONSTRUCTION/URIL11N0 METHOD: MUD ROTARY—AIR ROTARY AUGER CABLE OTHER <br /> -- <br /> I HE4BY CERTIFY THAT I HAVE PEPAFWD TMG APPLICATION AND THAT THE WOFK WILL BE DONE M ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND MULES AND <br /> MOLULATMNS OF THE BAN JOAOUN COUNTY.NOME OWNER OR LICENSED AGENT'S SIONAT VIE CERTIFIES THE FOLLONRIO:'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 IINALL NOT EMPLOY PES SLI <br /> RSONBJECT TO WORK/MAN'8 COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HITTING OR SUSCONTRACTNG BIGNATURE CERTIFIES <br /> THE FOLLOWNO: '1 CERTIFY THAT PH THE PERFORIANNCE OF THE WOR(FOR WHICH THIS MIMTT IS 1881JE0.1 SNALL EMPLOY PERSONS SUBJECT TO WOIIOMAM'S COMPENSADON LAWS OF <br /> CALIFORNIA. TIE ATICCA/NL�T M.USeT�C�J/l�1-�1 HOW IN ADVANCE FOR ALL MQUIRED 0'*1t\ TIONN At 1"014 4D42].COL04-VE DRAWING AT LOWER AREA PROVIDED. <br /> BIP,M X V �1�.. !►l`�/+./VT�Ia( TKN !)I'li Ile, y <br /> PLOT PLAN 0-1.S.dN 5..1. le <br /> 1.NAMES OF STREETS DXI OR ROADS REAFIEST TO OR BOUNOTHE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR POPOBED <br /> Z.OUTLINE OF THE NG POVERTY,OIVDIMENSIONS AND NORTH OFIECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> a.DIMENSIONED OUTLINES ANO LOCATION OF ALL EXISTING AND PROPOSED 9,LOCATOR OF WELLS WlTHT N RADILUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.NCLUDINO COVERED MEAS SUCH M PATIOS,DRIVEWAYS,AND WALX8. ON THE PROPERTY OR A"MNNO PRDI ERTY. <br /> I <br /> Iva <br /> kjdtRAP.. � � �c�ce 1 VhJ <br /> PAYMENT" —� <br /> PECE'IVED <br /> MAY 1998 <br /> JOAQUINCOUNTV <br /> D"ARTMINT USE ONLY DIVISION <br /> AeWbNbn Aewpld DY Dib Mr <br /> o1..A Inp.rlbn BF `fir In.o d-BY D.1. <br /> Owtnslbn Mwbll.n DM <br /> C.,.,,.,..,.• � o-Rvui— E rhe R � 1 C�VL�-+�' <br /> ACCOUNTNO ONLY: —1 LACI <br /> PE CODES FEE INFO AMOUNT REMI7ED C1EC !CASH AECBVED BY DATE POMETEERVICE REQUEST NU K"IR INVOICE <br /> D <br />