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• II � <br /> I <br /> [ Uri, APPLICATION FOR VlELLIPUMP PERR111.w0. <br /> I SAN JOA�OUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, E10X 38a, 304 EAST WESER AVENUE, STOCKTON, CA 95201383 <br /> (203) 488 3420 <br /> 0 <br /> NCH REFUYDARIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APNLICATIGN IS HERE BY MADE TO THE SAH JOAOUIN COUNTY FOR A PER it TO CON6IDUI1 <br /> CTAND/On INSTALL THE WOW DESCRIBED.THIS APPLICATION M MADE IN COMPLIANCE WTHI SAN! <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAGUM COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DORSID, <br /> JOS ADORF.6S/Cn APNI^T�.l� �� //cLl,�_ <br /> CIT) GFFJL PARCEL fi1ZE/nPNI <br /> OWNER B NAME �/✓V <br /> �/ AOORESB /- <br /> CONRMCTOR�D / ����n THIONE <br /> AnOnC6S Q� Ga1 Utlt-O=E�L, <br /> FVD CONTRACTORi� � 1'NGNE <br /> ADDRF.6C UCI <br /> - _ PHONE <br /> TYPE OF WELLS'LIMP: ❑ NEW WELL ❑ nF. CFMFNT WELL _ <br /> ❑ MONITDnINO WELL/ ❑ DITTIES <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR I� <br /> : ❑ CROSS <br /> MPCONNECT REPAIR ❑ VAI'p11 E%iMCiION WELL <br /> ❑Neer❑Rpnb ILP, .l <br /> HYPE OF I'UMPI DEPTH PUMP SET FT, FIRST WATER LEVEL <br /> O <br /> ❑ OUT Or SERVICE WELL r IJ GEOPHYSICAL WELL A ElSOIL AOnING <br /> ❑OcF1LUCTION� 6 <br /> I INTENDED USE 'TYPE OF WELL CON6iRUC 110N 6p EC IFICAiIONA <br /> II❑ INDUSTRIAL ❑OPEN BOTTOM DIA.,OF WELL EXCAVATIO N �( �) <br /> �❑ DOMESTIC/MIIVAT DIA.OF CONDUCTOR CASINO N/� D <br /> E ❑GRAVEL PACK/SIZE TYPE OF CMIND/STEP V �(/ <br /> "❑ PUGLIC/MUNICIFAL C1 DELVED DIA.OF WELL CASINO O <br /> OEMII OF GROUT SEAL SPECIFICATION <br /> i❑ IpRIGATION/AO ❑OTNEn /�� Oc Z 6 <br /> I LrY,/ GROVE SEAL INSTALLED BY > GROW SOUND NAME <br /> MONITOBINO /�}� GROUT SEAL PUMPED: ❑Yr yCl Nu E <br /> !:APPFO%.DEPTH .21]1 CONCRETE PEDESTAL BY DRILLER:❑Yr S <br /> LOCKING MIESTE90-,PV <br /> T VE PEE <br /> PJ <br /> PROPOSED CONSTRVCTION/DLUNG METIb D: MUD ROTARY S <br /> AIR ROTARY AUOEnCABLE OTHER <br /> II <br /> 'T <br /> 'REGULATIONSEOVUGULAY CERTIFY THAT I HAVE PREPARED TIONS OF THE SAN JOAOUIN COUNTY.TIIIS APRNCATION AND THAT THEiWOb(LMLL OE GONE IN ACCORDM1NCE WITH PAN JOAOUIN COUNTY ORDINANCES.6'TATE LAWS,AND RULES A-110HOME OWNEn On LICENSED AOEN 'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW(FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO W ORKMAN-A COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS HINNG OR SUB.CON TEACTINO SIGNATURE CERTIFIES <br /> iTHE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW(POR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOnKMAN'e COMPEN))))))ATION LAWS OF <br /> CALIFDRNIq.' THE AP ANT MUST 2A MB IN ADVANCE FOP ALL PEOURED INAPECTIONS AT 130`1480D 23' COMPLETE DEAMNO AT LOWER AREA ED <br /> 1 <br /> j( Alvrnd Tllle <br /> l Dae <br /> ROT PUN IDr.vr to SnNel SEJ. 'to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING TINE Pn0r4nTY,' <br /> 1. OUTLINE OF TINE PDOpFRTY,GIVING DIMENSIONS ANI)NORTH DIRECTION. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On P,,MSEO <br /> J. DIMENSIONED OUFUNES AND LOCATION OF ALL EXISTING AND PROPOSED I EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> r STRUCTURES,INCI DOING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDREO FIFTY FT. <br /> ON THE PROPERTY OR ADJOINN4G pp,,,nTY <br /> LEPMTMcNT:...i SNL: <br /> AjPticalen Accepittl IY II - 2 '. <br /> ' 1 Dnb �•Zl` L � Aye. <br /> D'I n:mp m.ozvon Ay i <br /> De.Rltnon Ir,�n^eE"no�n�Br ,,��IIm ll�� <br /> com nn.' r1Gl[.L.WO✓YIL s}- Elf. /,DVM y�• VJ' 1 r3D Dele <br /> dCi�S ap fD field IAD,^IR Su f1r f n ((K 4ti5 MMPlt ��(a45f Wd kl/Lp <br /> ACCOUNTING ONLY: AIOI :I FAC# i <br /> PE COD�I a INFO AMOUNT REMITTED CHECKIMAIIN RECEIVED BY DATE PETV IT/A TV CE REQUEST NRAAEn INVOICIF <br /> Pub.Health Sew. Envirc, 173(3/96) it j <br /> I <br />