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r <br /> APPLICATION FOR WELUPUMP 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 /> XOX•REFUXDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> tCempMle In TrIpReBE61 - <br /> APPLICATION IB ITERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PEFIMPT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRRED.TTRS APPLICATION IB MADE IN COMPLIANCE WRII BAH <br /> JOAQUIN COUNTY DEVELOPMENT TITI.F,.CHAP-TIER 9-17 15.3 AND THE STANDARDS OF BAN JOAOUIN COU ft1BllC HEA1.711 SERRV]ICES.ENVIRONMENTAL HEALTH ammoR. n L <br /> JOB AODRIEBSIOR AMI /JA�C! 7 I,�) CITY J�J1I ! + PARC[L R12E/APN,f /'/(��eJ <br /> OWRRR'R NAME 1 J / ! L I f(,10! SA DURESS f/E <br /> AIONE r `J , 9 <br /> CONTRACTOR At I ADDIIESBMn .0 MANEImo]..r, �9 <br /> RUR CONTRACTOR I ADINIEBS LRCf <br /> PI---�r P-t E-1 RIONE f <br /> OF WELLRTIMP- ❑NEW WELL 1_J RFILICTMENT WELL 1L^--JI MOINTONNO WELL/ 1I Or11ER <br /> ❑-t MSFIA--T�LATION ❑WELL SYB FFM RFPAIR A..!CROSS.CONNEGT REPAIR Q VAPOR EXTILACI WN WELL f// <br /> L N.w I_IRw.F IR.P. DEPTH PUMP SEF FT. FIRST WATER LEVEL -/(/ O <br /> H YPE OF PUMPI r�-t <br /> l // ❑OVTAF-SERVICE lL LJ OTOPNVSICAL WELL f ❑ ROIL ROMNO <br /> ,,,LLLaa.((( I / P <br /> DESTRUCTION! 1 e Uw 1, --.f ,y / `� /J��s, / <br /> 1 4, <br /> II-N�aTFNDEp UFE 1tT----Y�IPE OF WELL CONSTRLtC rION SPECIFICATPONB A <br /> EI_T INDUSTRIAL 1_I OPEN BOTTOM DIA.Of WELI.EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> DOMESIKIPIVAIF E0 GRAVEL PACK/BILE TYPE OF CAenIO/SIEELIPVC DIA.OF WELL CASINO O <br /> E--I FYIBLICMVNICrPAL �L-JI DRIVEN OEM 11 OF GAUUT BEAL MECITICATION - A <br /> O IRNGATION/AG LJ OTHER GMUF SEALI NSTALLED BY OFq UT Kr AHD NAME E <br /> ❑MONITONNVI GROUT SFALPUMPED:Ely- ❑N. CONCn 1PEMBTALRYONLLEB:QYr ON. S <br /> AMID X.OTFFN LOCKING CNEe T[n BOX/S GVF PIES S <br /> PROPOSED CONBTRLICTIORMIRILUNO MEPNGD: MUO ROTARY AIR ROTMY AVOER CABLE Oi1FER <br /> 11 <br /> 1 HE9ERY CERTIFY MAT 1 IIAVF PREPARE0 TNIO APPLICATION AND 7HAY THE WORK WILL BE DONE M ACCORAANtF WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> TKOLAAIpNB Of THE BAH JOAOIIIN COUNTY.HOME OWNER OR LICENSED AOENT'B ONATURE CE"XIEB THE FOLLOWING:'1 CERTIFY THAT M THE PEIIFOMAAMCE OF THE WORK FOR WHtCII <br /> THIS PERMIT TB ISSUED,I SHALE NOT EMPLOY PERSONS BUSJECT TO WORIURANSI <br /> 'B Ca1APENFATION LAWS OF CALNOFMA.'CONTRACTOR'S I""NO OR OU"OIRRACTING SIONATURE C[1,771[B <br /> THE FOLLOWING: '1 CFlrFIFV THAT IN TIE PERFORMANCE OF THE WOR[FOA WMCH'Me lLL"[[CCne""IB ISSUED.1 SHALL EMPLOY REAPONS SUBJECT TO WOMMAN'B COMKNSATTGM LAWS OF <br /> CAUVORMA.• THEM �ICAI T MOST CA NOIXV IM ADVANCE FGR ALL REOUIq i IN//Sl))��JJJJ////FITONS AT T»61 Stl-}PT!-COMMrXTE OMWM AT LOWER AREA PROM ED: <br /> BCW K �7�, Tleh - Ort• <br /> PLOT PLAN 10—to Saab]Bal le <br /> P.NAMED OFR REE7R OR ROAOR NFAMOT TO OR BOUNDINCI THE REOIERTY, 4,LOCATION DIF IIOUBE eElrfAaE pBPOSAI BYBTFM OR P1gPOELD <br /> !.OUTLINE OF THE PnOPERTY,GIVING DIMENSIONS AND NORTH DIFIECTIC EXPANSIpH OF sewAOE DISPOSAL SYBT[MB, <br /> f,OtMENWOMED 13117MNF6 AND LOCATION OF ALL EXISTING AND REOpo S.LOCATION OF WFLLs VAMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDINO COVEIgD AFEAB SUCH All PATICH,DRIVEWAYS,AND WALK S. ON THE PROPERTY OR ADJODIING PRop,,ty, <br /> ll <br /> ILI- <br /> 0 <br /> a <br /> r <br /> .......:......... <br /> ........ <br /> /� //� OEFAwTMa"T Vol ONLY /yi d 7-,57p <br /> AOPIl.r,lsn Aaawled IV ��� -"�' „' - I D. ��//-7[ !7,- <br /> Ma.A IMPrall.n BT Oas pl—1n.—d-BY prlr <br /> U-11eG..1—IIe.,,RY—C.G' L�-(� fL.. 4� "0715 <br /> cr.....a..I.: Ail� I.QI -- -- L ..w <br /> /�/ � SG:r;ICC�%x-.r�a,�'Iwy�a�f� g f/ � .��✓C �7'C...-+� <br /> / <br /> ACCO VN PING GARY: AIDE <br /> PE CGbE6 FEE INFO AMOUNT REMITTED (CASH RECOVER By DATE PErf"MTISERNCE 9EGI1F67 NLM69t INVOICE <br /> I <br /> I <br />