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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES D j �lt7jj <br /> ENVIRONMENTAL HEALTH DIVISION IYLE `�1�u� 'EI� <br /> P.O. BOX 388,304 EAST WEBER AVENUE, STOCKTOR CA 95201 <br /> (209) 46e-3420 FEB 0 3 1997 <br /> ROE-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> IDNST .L.M EHOR 11.1 ENVIRONfv1ENTAL� <br /> APPLgATION 19 HERE DY MADE TO THE BAN IOAOLIIN COVNEV FM A PFRARE TO CONSTRUCT AWAR INSTALL THE NIOR(DESCRMFD.TIBB APPLICATq �1{�@L) 1 SAN <br /> JOADUN coUNEY DVAL'O7PMMENF TEELE CHAPTEN 8-11�1�6.3 AND TRIS BTAHDARJe OF SAN JOAdIM COUNTY[VBAC HEALTH sERVICEe.p/VebNEEEM��ylblklbti7! <br /> Joe ADMESSOR APINI T� V��S �M--E .cam I.�JhY\) CITY <br /> MNIER'B NAME ��r'cw",••TrI 4^/'iI'11\��-, g�t. T^1"�`L ,-' �-`T ES1�1I-ZV1LA'R-/N1 <br /> Ananii" ✓ PHow <br /> , <br /> ADDRESS3I4nW <br /> NE 451c)'Al) <br /> CONTRACTOR C/YhW <br /> PUCOMMCTORgMe�V )u"mobpiC <br /> /!� ��l-IEl <br /> TYPE OF WEIl/PI1MP: ❑ NAV WELL ❑ RERACEMEM WELL MOMTDINIG WELL/tJ4i` ❑ OTN[II <br /> ❑ INSTALLATION Cl WELL SYSTEM REPAIR ❑ CIOD ONN[CT REPAIR ❑VAPOR WIUCTION WELL/ J <br /> ❑N—❑Ree W M.P. DEPTH RUMP IEET_FT. FIRST WATER LEVEL O <br /> HYPE OF PUMPI <br /> ❑ OUT-0E-6ERVICE WELL ❑ OEOPIIISgA W4LL/ ❑ SM.BDIEIIB B <br /> _ ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION AMIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM f DIA.OF WELL EXCAVATIONt� D0.OF CONDUCTOR CASIMO p <br /> ClN <br /> DOME9MM ATE gGRAVEC% <br /> L PAISITE— _ TYPE OF CASIELUPNC NGMTEY ` UA Of WELL CASINO <br /> ❑ RIeLN:iT.1UN!CroA ❑ovSwN DEPTH Of GROW SEAL -JS l-,+ BPECw 710" :5 <br /> ❑ IPMOATMNIAG ❑OTHER GROUT SEAL INeTADE,�B'11Y �✓L ! `� GROUT BRAND NAME �J E <br /> E3 IAONUORNO r GROUT SEAL PUMPED:L}Y� ❑EM CONCRETE PEDESTAL BY vPm ER:❑Y- pN Me s <br /> AP X.DERV •F�L7 L.++-� L000M CHEATER ep%ISEow PIPE L s <br /> AIOPOSEO CONSTIIUCTONIDRIWMO METHOD: MUD ROTARY AM ROTARY ALOEIR_�CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORC WILL BE DONE M ACCOMANCE'MTH SAN JOAOUBN COUNTY ORDINANCES.STATE LAWS,AND RULES ANO <br /> PMUTATION9 OF THE SAN JOAOUIIN COUNTY. NOW OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWING:'I CEREIFY THAT M THE PEAOPMANCE OF TETE WOR(FOR WHICH <br /> TMR FEWIT IS ISSUED,1 NNAU NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPONSATON LAWS OF CA MRRIL- CONEMCTORS HREFq OR W ONTIUCTDA BANATVAE CERTIFIES <br /> THE FOLLOWING: -I CETIFY THAT M TETE PERFORMANCE OF THE WOR(FOR WESCH THIS PENRT M MSUED.1 SHALL EMPLOY PERSON!SUI TO WORIDSAN'S COMPRDIEATION UWS OF <br /> CALNORMA.' THE APRU MT IMT CA/LLyJgUPS IN ADVANCE FOR ALL REOUIISD/PHIMMIMICyTIOMMSS AT I2081 AM-Lff/.COOMM/P_IZFE ORNIIMING AT LOWER AREA PAKPAVED.D.. <br /> EH"M%� J///iF{�Ifyl i T1N�U��S //.C9I.lANT/GI DM. <br /> PLOT MM R).eYN I.BePNI Ae.l. 'M1 <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PIgPEIOY. A. LOCATION OF RAUSE SEWAGE DISP09A SYSTEM OR PROIOSM <br /> E. OUTUME OF THE PROPERTY.ONIPO DIMENSIONS AIA NORTH dRECTOH. EKPANSION OF SEWAOf DMI OSA SYSTEMS. <br /> 3. DiWHMNED OIUTLINFB AEA LOCATION OF AL E%IBTINU AND PPUPDSEO S. LOCATION Of WFIL WTIIN RAUUS OF ONE NIMOrtp fIFTY R. <br /> STRUCTURES,INCLUDMq COVERED AREAS SUCH AS FAME.DRIVEWAYS.AM WA(S. ON THE FROFflRY OR ADJoIIRNa PROPERTY. <br /> DEPARTM1.0 <br /> SE NLY <br /> J <br /> Ary1M.lbn Aw.elsi DT OM. � � M� <br /> OreU Mpsllen DY DN.__ _ RPnI BY OH. <br /> D+,n�Oen IrwvmOen BY -��f OM. <br /> Ole- <br /> ACCOUNTINO ONLY: AIDS FAC/ <br /> PE CODER FEE INFO AMOUNT REMITTED CMCKIAAAH R[CEVED SY DATE PETIITRFRNC[R[GUEST NUMBER INVOICE <br /> p L3,B` / 30 17 0 53 / <br /> Pub.Health Sam.-Emiro.173(3196) <br />