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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 /> NO&AfFUNPAPLE FERMITE RES I YEAR FROM DATE ISSUED <br /> (C•NFIPt•IN Tr*lhata) <br /> APPLICATION le IIFRE eY MADE TO THE SAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT ANDAOR INSTALL THE WOW DESCRIBED.TIDE APPLICATION 19 MADE IN COMPLIANCE WITH SAN <br /> JOAOUOL COUNTY DEVELOPMENT TITLE.CHAPTER B•1116.3 AND THE STAIgNDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH 9EJTVHCEO,ENVNgNMEMAL HEALTH DMSION. <br /> JOS AOORESMK APW ,CL K/JQ(/D�AO_OIESS CITY t/0 �PARCEL�SRE E1'ILAgINEl <br /> OWNEAY NAME A�NF9�LL_.y_y9.S. <br /> 9 <br /> CONTRACTOR ©LV A1,64- ADDRESS / �RgffE l <br /> SUe Cowr ACT011 ALIOREWS BIO/ 11.011E0 <br /> TYPE OF waurmp: ❑NEW WELL ❑REPLACEMENT wuL ❑MOI•Ta TNO WELL N ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR Cl CROSSCONNECT WANT ❑VAPOR EXTRACTION WELL 1 s <br /> ❑N«.❑Fw. P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> HE APP <br /> ITYOF RII <br /> oFsERwcE wEtl ❑nEDPETYs¢AL WELL* ❑ sat sowH.0 • <br /> ❑DESTRUCTION: <br /> INTINDFO USE NSTRUCTION 110WIFKATIONS A <br /> ❑NOIISTMAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DU.OF CONDUCTOR CAAM O <br /> ❑DOMESTICIINIVATE ❑GRAVEL PACK/SRF TYPE OF CASNONTFUJFDIA.OF WELL CASH O <br /> ❑PUSUCaMUNICtPAL ❑DRIVEN DEMN OF GROUT SEAL SPECIFICA110N R <br /> ❑RR OATIONIAO ❑OFwFt OROUT WAL NWTAUM SV GROUT IRAND NAME F <br /> ❑MONITORING GROUT SFAL PUMPED:❑Y- ❑N. CONCRETE PEDESTAL VYDRILLER;❑Y. ❑N• s <br /> APMOX.DEPTH LOCXaFG CHESTER BOXISTOVE PIPE s <br /> PROPOSED CONSTIITICTIONICIVULWO MFTNDD:MIX)ROTARY AIR ROTARY AUGER CASA OTHER <br /> I REIEBY CERTIFY THAT 1 NAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE N ACCORDANCE NATAL SAN JOAOUN COLMTY ORDINANCES.STATE IAWO,AND MILES AfaH <br /> REOULATIONS OF THE SAN JOAOUIN COUNTY,NOW OWNER OR LICENSED AGENT'S SOHATURE CERTIFIES THE TOLLOWNO:'I CERTIFY THAT N TIME PERFORMANCE OF THE WOPR FOR WHICH <br /> THIS KRAFT IS WORLD.1 SHALL NOT EMPLOY PERISONS SUBJECT TO WORSMAM'S COMPMOATION LAWS Of CALIFORNIA.-CONTRACTOR'S HIRING OR NUS-COMRACYING SONATURE CERnra@ <br /> THE <br /> POIIOWINO:f./{SMIRTFY THAT N PFTFOwHANCE T1FE YVDIK FOR WHICH THIS PEW.aT IS ISWED,I SHALL EMPLOY RMONS SUS.ECT TO 1NORIOMANFS COMPENSATION UWS OF <br /> CA�R011MA.'/I Y/ CAM MVSt C 7N/10W AVCS POR ALL REOIMIW WSFSCTgRS AT t10S14b?I SS.C.P1.11 dFAYNNO AT LOWER NEA R10VIDED.f <br /> SISrrw X �JJ/i TRN 0.. '511 �I <br /> n� ROT RAN M.—H•War.l B"R 'M ` 'S <br /> 1.NAMES <br /> Of <br /> •t1Efi0 OR ROADS NEAREST TO OR BOUNDING 1M pf"wiRY. S.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PPOPOSEO 1VI1"1 <br /> I.OUTLNE OF THF PROMIRY,GIVNO DIMENSIONS AND NORTH DIRECTION. EXPANSIONYST <br /> OF SEWAGE DISPOSAL WEMS. <br /> f.DIMENSIONED OUTL/RS AND LOCATION Of AIL EXINTNO AND PROPO/M S.LOCATION OF WELLS WITHIN RADIUS Of ONE HUMORED FIFTY FT. <br /> •TRUCTUFES,INCLUDING COVSED AREA/SUCH AS PATIOS,DRIVEWAYS,AND WALX0. ON Til!FIgPERTY OIL ADAMM AOPEMY. <br /> : t i...v... <br /> kric ' <br /> :. .' RAs. <br /> 1Ti/8l ,'H'iEP T1t 9FPiVi6C3 <br /> ' ViR NN I:N'\I,HEYt'fH;�IVIRIL`t> <br /> Dw*m <br /> q+v LS Q L��'V�V�/\ /L\ENT D..GNIY u�1y <br /> ApINYI•n A•wPIM w _ Go._ Q� O A— <br /> a—k"p-ft <br /> —a—NSPmf.BF DN• R.+ro BY O.t• <br /> D�Irtcf.n Irw--eT OM• <br /> a b <br /> AeeeUNTINO ONLY: A10T FACT <br /> R <br /> CO DU FEE NFO AMOUNT RETNTTED C NCXTIC H I4CWM IV DATE PNMTISOIVICE PM42MT NUMBER INVOICE <br /> a)�a <br /> `,f Pub Health SBrV.-E Niro.173(1/97) <br />