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11—OS-1997 1.55PM FROM P-2 <br />APPLICATION FOR WELIJPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ; <br />ENVIRONMENTAL HEALTH DIVISION C�ls� 41 , <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202' 11/R 2� <br />(209 as$ -sato �Fy,1;���` �0a0 e) <br />ROW -RU VXCABLE PERMIT EXPIRES 1 TEAR FRON DATE ISSllEA <br />W&mpVu 1G TrfpikatAl /LS'�` ry , . <br />APPLICATION IS HEBF SY MADE TO THE SAN JOAOUW COUPSTY FOR A POUAT TO CONSTRUCT ANDIOR INSTALL THF WOW OESCRIBED. TUBS APPLICATION TO IN CO"I'"ANCE VAT14 SAN <br />JOAOUW COUNTY DEVELOPFAENr TTnF• CHAFFER 9-T 115.E AND THE STANOAROS OF SAN JOAOU N COGHTY PU0l1C HEALTH SER94k:M E'NVR0FaAUffA1 HEALTH PT, S <br />(1 [ }I E -IIP., , / ��_ /� f� ��/ <br />JOB ADDREBE+VR APNI_,� OO wto J' �C� G, .-� 1. G ✓t i' CITY (l�: / PARCEL BQF/APNI /(96 /z�-C)Z-0-GC) <br />OWNER -9 NAME J - ADOIQ3i ri�YN ��I�c /��c+c� ��,�vp•� �n �rc,fy PHOWe.6 %-f�L�-/7CiJ <br />CONTRACTORS U Z ✓ .r. �n r AODATEB / L 111 <: r �c . UCrf,�/ pwo%E r 9/6 �,,G <br />QUO CONTRACTOI! '`Gt5 P+�e I /r i I I i �1 L. /�) . AODRTQ683Z 2-q Zi/A - 6 �- <br />TYPEOf V L UAAP, ❑ NEW WELL ❑ w--LAcrmcwT w*TL IL WOWTOPMtl wail. 12 1„/(_'. II5 ❑ or71FR <br />❑ INSTALLATION ❑ W*LL SYSTEM REPAIR ❑ CFO BB-CU/R*CT r4wA0Aw / O /pt Cl VAPOR EXTRACTION WELL / J <br />❑ H— ❑ Po H P- DEATH P u%w WT FT, U > FIRST WATER LEVEL O <br />ti YPE OF PUMP) <br />❑ oUTOFSLRVRC'L WELL ❑ OFOPNrOCAL WELL r ❑ BOR BOPoNG <br />e <br />❑ DESTRUCTION; <br />INTENDED UA[ <br />TMD{ Of WFIL <br />CONATAUzr T10•I APECDiCATTONA <br />R COOEI <br />A <br />AAIouNT RATAITTED <br />❑ I+OVSTMAL <br />❑ OPEN BOTTOM <br />DIA. Of WELL EXCAVATION <br />IRA. OF CONDUCTOR CAVING <br />O <br />FRT <br />❑ OOAAEBTTCIVATE <br />❑ OREZ AVPACXIBF2E <br />TYPE OF C.Pl o ETEEZJP1C 10 ✓(/ <br />OIA• OF WELL CASINO Z ) K -j <br />D <br />❑ PUSUCAWNICTrAL <br />❑ QIWTN <br />OEMN Of OROLIT SEAL I. C�, -'e �, G r d 1, <br />_ <br />S z"cOF1GATgN <br />A <br />Q <br />El IRRIOATIOWAG <br />❑ OTWER <br />(TROUT ZEAL V.STALLFD BY <br />GROUT BRAND NMA! <br />E <br />O <br />�J VIONfTOTONO <br />ORiO/JT SEALUM <br />PPED! ❑ Y-+ ❑ W <br />CONCRETE tfT7'EBFAL BY DR7R ❑ Vw ❑ Ib <br />-s <br />/ / <br />/� <br />((y`_ <br />ArMOX. OWTH () �j <br />6 (9/` <br />✓i r� -,r <br />UiCX"40 CWSTER SOX/STOVE Pw-r <br />S <br />PNOP0903 Co NAT1RICTIOKf0MLURO &MTHOD; YUO ROTARY <br />AIR PIOTARY --,l I, . �"UOFR <br />OTHER <br />V <br />. <br />1 HEREBY CERTTFY THAT I NAVE PREPARED TMS APMJCATTOPf AND THAT THE % OFW %"U RE DOH* M ACCORDANCE WITH BAN JOAQUTN COUNTY ORDINANCES- STATE LAWS. AND RULER AND <br />MCULATPONS OF THE BAN JOAOVM COtPfrY. HOME OWNER OR L)CENSED AGENT'S SIGNATURE CERTKKS THE FIDUOWNO; -1 CERTIFY THAT IN THE PEWORIAANCE OF THE WOm FOR WHICH <br />TWO FERPALT re ISSUED- 1 SHALL NOT E34PLOY P£RQONG SURACT TO WORRAAAN'S COAAPEWAATION LAWS OF CALIFOF"A.' CONTRACTORS HSbNO OR SVS-COHTAACTMO SIGNATURE CFXTWW6 <br />THE FOLLOV4NO: -- I CERTIFY 774AT IN TITE PfRFOFWANCE OF THE WORK FOR VMICH TWO PEMIPT TO lSeUED, I SKALL OAPLOY PEIISO" $,TRACT TO WORIOAAN-S COPAr"ALATION LAtNf Of <br />CAUcpNTTA.' THE APPLI AM VIIE'HOIIRA T}I ADVANCS FOR ALL RFGlA4lED LFIS►VCTbNs AT DTwt 4q JM,2], COueuTg OMv1•ING AT LOWER AA'EA Ti1pVRJEV. <br />PLOT PUN w•.• Te H -w <br />1. NA{AEB Of STREETS OR ROADS NEAREST TO OR OOUNDNAO THE FMITRTY. <br />2. OUTLINE OF INE M OPERTY. GrANG I)MENSLONs AND NORTH 01MCTI044. <br />7- DIIAENWONED OVTLMF,B ANO LOCATION Of ALL EXISTING AND PROPOSED <br />STRUCTVRES. WCLU01N0 CD%fM0 ARFAS SUCH AS PATIOS. DRIVEWAYS, AND WALKS. <br />.T: )�a <br />APPITe.tIv.I A-.OIfd BY /`•"V <br />O.,.I.vnbn <br />b -- r— BT <br />b <br />A, LOCATION OF HOUSE SEWAGE 019POBAL 67TTE44 OR PROIOSED <br />EXPANSION Of WWAOE DISPOSAL OYU%-Eue- <br />6. LOCATION OF WELLS wfTTRN PAGERS Of ONE HU►OfFD FIFTY FT. <br />ON THE PROPCIrTY OR ADJOWMO PROPERTY. <br />.....5... .. <br />.........a......:.... .. .. <br />..` <br />DEPARTMENT VIE ONLY % <br />D.I. g <br />12 e—a 9--P-0- BT PAI. <br />w /fie., <<" t6 -f - , ( 'Z/ <br />ACCOUNTING ONLYz <br />ATOP FACS <br />R COOEI <br />FEE two <br />AAIouNT RATAITTED <br />CHIC ASH <br />FQCETVEO it <br />OAT] REGVEST ER <br />WIWI" <br />UO Z 3�3 <br />Pub. Heafth Sete. - Envkm 173 0AM <br />