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APPLICATION TOR WELLIPUMP PERMIT /"'j 538z. <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES �wv <br />ENVIRONMENTAL HEALTH DIVISION <br />/ P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br />(209) 468.3420 <br />MON�_REFUIIIIADLE PERMIT.EXPI_RES 1 YEAR FROM DATE ISSUED <br />-- (Complete In Triplicate) <br />APPLICATION PSIIF. RE nY MADE TOTIIE SAID JOAOIIIN COUNTY FOR A vrnPAIT TO CONSTIILICT AND/nn INSTALL TIIF WOrv,, OFSCNRFD. TPIT S Arft ICA TION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOP <br />MENT IULF. CIIAPPTFn 9-1 115.3 AND IIIE ST ANOAnnn OF SAN Jn A Of IN COI I HTY Pl/RLIC nr AI.TII SFRVICFS, ENVIRONMFNTAL IIF ALT If DIVISION. <br />JOB ADDRESS/On APNJ S'. CberrD I2eag,joy <br />1 PAnCFL R12FJArYJ/ <br />OWNER'S NAME J" `YtYLw.J ADOI1FSft r� �. /w,y/^/y <br />^7 v� �4j <br />�y�PHONEJ�—/"/',v <br />CONTRACTOR✓/���/�2Q1j✓%/y%COOOFSF� 11C' ((/GGi� f`IIONF / CO �WGY. <br />RUB CONTRACTOR •� ADDlIr RP, n ICJ n P110NF.I I <br />TYPE OF WELL/PUMP: ❑ NFW WELL ❑ nFI'LACEMFNT WFIL _ -_' ❑ MONII ORINn WRL / -" —_ ❑ OTIIFn <br />❑ INSTALLATION ❑ WELL SYSI FM nFPAIn ❑ CnOSS C.ONNFCT nFPA1R ❑ VAFOR FXTRACTION WELL 1 <br />❑ <br />(TYPE OF 1'UMPI New ❑ Ilepelr H.P. nFPT II mimr SET FT. FInP.T WATER L� <br />FVFL ` <br />ry/ <br />F ❑ OUT Or-SFnVICF WFIL ❑ nFOPI IYSICAI. WFt.L J IfCI SO n. BORING R <br />❑ DESTRUCTION: <br />AID/--rFACJ—_—_---_----_� <br />PE CODES <br />FEE INTO <br />INTENDED USE TYPE OF WELL C_ONSIRUC110N SPECIFICATIONS --- ^ <br />CIIFCKNICASII <br />❑ INDUSTRIAL ❑ OPEN no TTOM DIA. OF WFIL EXCAVATION_ 2-, Z S // DIA. OF CONDUCTOR CA.n.INn <br />DATE <br />D <br />❑ DOMESTIC/PRIVATE ❑ onAVFL PACK/Rl7E <br />INVOICE <br />TYTY or CA61Nn/CTFFI/PVC__ DIA. Or WFIL CASINO D <br />❑ PUBUC/MUNICIPAL Elomvm DEPT 11 OF <br />GROUP SEAL 6r4CIrICATIONe—/ R <br />A42 <br />❑ IRrOGAT1ON/AG ❑ OTHEn GROUT 6FAL INET At I.ED nY ' OROUT BRAND NAME E <br />C�MONITORING <br />/ rF--'�yT <br />C / GROAT SEAL F'1/M T70: ❑ Ye. No CONCnFTF. PEDFSTAL BY DRILL Fn: Ely— L'7No g <br />APPnOX. DFPTN �� LOCKING CHFRTFn ROXJRTOVF MPF <br />PROPOSED CONSTRUCTION/DRILI1N0 METHOD: MUD ROTAnV Ain ROTAnV AUGUR _ CABLE OTHFnyE�011 L]Lr� <br />I IIERFBY CERTIFY TIIAr I HAVE I'11FPARFD THIS AIY'LICAIION AND TIIAT 114F WORK W11_1_ RF DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. S IIATTEELAW�S, ,—ND nUj E8 AND <br />nFOULATIONS OF THE RAN JOAOUIN COUNTY, HOMF OWNFn OR LICFNSFD Anr NT'R RIGNATl11117 CFnTIFIFS TIIF rOLIOW1Nn: •I CFITTIFY THAT IN TIIF PFRronMANCE OF TIIE WOq( ron WIIICII <br />THIS PFnMIT IR IRRUFD, 1 SIIAt L NOT FMPIOY PFnRONR SUBJECT TO WOnI(MAN'S COMPENSATION IAWA OF CAI IronNIA.• CONTRACTOn'R IIITUNG On STIR CONTRACTING 610NATUnE CERTIFIES <br />' <br />TIIE FOLLOWINO: 1 CEn-tirY TIIAT IN TIIF PFnronMANCF OF TIIF WOrn( TO11 WIIICII TIIIS T'FRMIT IS ISSIIFD, I R11AtL EMMOY PERSONA SIIRJFCT TO WOnKMAN'e COMPENSATION tAWB OF <br />CALIFORNIA.' THE APPUCANT MUST CALL 24MUne IN ADVANCE FOR AlL nFOt11n FD INSPECTIONS AT 12091404-3423. COMr'LFTF DRAWING AT LOWER AnFA PROVID/E <br />Signed X4� <br />D.te V <br />MOT MAN (o- to Radel Sale to <br />_ <br />1. NAMES OF RTnFFTS On ROADS NFAnEST TO OR ROUNDING TIIF PnOPFnTY. e. LOCATION OF HOUSE SEWAGE DISPOSAL SYRTFM On PnOPOSED <br />2. OUTLINE OF TIIE PROPFRTY, GIVING DIMENSIONS AND NORTII DInFCT ION. FXPANSION OF SEWAGE DISPOSAL SYBTFMB. <br />3. DIMFNSIONED OUTLINFS AND LOCATION OF ALL FXIRTINO AND M10POSFD 6. LOCATION Or WFt I.R WITHIN RADIUS OF ONE HUNDRED FIFTY rT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCI1 AS PATIOS, DnIVEWAYS. AND WALKS. — n¢ onnnc —..n ... r..................�._.., <br />Appll-11— A ... pt d By <br />O—A Impnc Uon By <br />Du.lRrtlen In(./py'Ilon Py <br />Cornmeal.• `.A,p 1'y <br />DFPAnIMFNT USE ONLY <br />D.te �� f4unn In.neetton By <br />Arse C) , Jh <br />I ACCOUNTING ONLY: <br />AID/--rFACJ—_—_---_----_� <br />PE CODES <br />FEE INTO <br />AMOUNT REMITTED <br />CIIFCKNICASII <br />RECFIVFD By <br />DATE <br />------------------ <br />PERMIT/SFTIVICF nFGUF6T NUMRFTI <br />INVOICE <br />01 <br />A42 <br />011 L <br />-[-Zm/71 <br />Pub. Health Serv. • Enviro. 173 (3/96) <br />