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APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NOMREFUNDARLE P_ERMIT EXPIRED 1 'FOR FROM DATE ISSUED <br />ICimalets I. Tolpficsta$ <br />ARPucmpori IA HEM SY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMET TO CONSTRUCT Wpm INSTALL THE WOW DESCRIBED. 71111 APPLICATION IS MADE 114 COMPLIANCE WITH IAN <br />JOAQUIN COUNTY DEVELOPMENT WU. CHAPTER - 1 11 6.3 AND THE STANOARDs OF SAN .10,40uEN cOutiTY KMIEC HEALTH SERVICES, ENVIRONMENTAL 1,EALTIT DORSION. <br />crTY PAEC'21. WEN". 2139 - 2100 1/ <br />ia-v -c , <br />ADINIESS F;"CA-rt.•./f, • et 4' 53 4..^1. PI-IONE • / 4 a cx...) <br />116-01/ •3 Y Ammo! p I c 14- ?'1i'' .4*/ 4 PHONE 77-4)6. —0 c <br />5 <br />'9 7 Loots <br /> <br />SD <br />ADDRESS f iqme '7 wow • 37-15 2 9vei r <br />motirromia WELL • 4 4 e - 0 OD" <br />ci CROMLCONNECT REPAIR VAPOR EXTRACTION WEIL r <br />DEPTH PUMP SET FT. FIRIFT WATER LEVEL <br />GEOPHYSICAL WELL I 0 SOIL EICHING a c" <br />0 DESTRUCTION: <br />Joe AbonEestoR API*/ / L -J. L. < C. <br />°mown HAW k Jop ete. le-crk Z"-a C. • <br />CORI EtAcToR cry p <br />RUS CoNTRAcToP .-A.Jc • <br />(TYPE OF PUIAPI <br />g TYPt OF WELLTPUMP; NEIN WEU. 0 REPLACEMENT wELL <br />INSTALLATION 0 VIVI cr. e arEm REPAST <br />0 II... °Rom* HP <br />0 OUT•oF BERME WELL <br />INTERIM UNE <br />OINDUION <br />o DOMEPHCAIRNATE <br />o <br />o <br />PUSUCATUNICIPAL <br />IRMGATIONJAG <br />)4 MONITORING <br />APPROX. DEPTH <br />PROPOSED CONISTRUCTIONTEIMUJINI TAETHoor MUD ROTARY <br />CI OPEN BOTTOM k•c_ - <br />GRAVEL PACXTRELE J <br />DISKFT <br />0 0THIR <br />TIRE OF WELL comornisc nom SPKIFICATEONII A <br />0IA. OF WEIJ. EXCAVATION_ L.. it DIA. OF CONDUCTOR CASINO Ici e.t./I/ f), <br />Tyr!. OF CARIKIMEEEIJPVC S,^ ii_ 4*C) P i,' t.. 01A. OF VVELL CASING _1_, r * r _ 0 <br />DEPTH OF DFloUT MAL SPECIFIC AT ION 4 <br />a Rout SEAL RrAtAttle BY 7 .; • .,ors•EL 14:-.• -e GROUT MIMED HAW Ci„. . 1-E-- <br />GROUT BEAL PLGAPEOI t4 YA, IlltIN CONCRETE PEDESTAL NY :WILLER. Yea ON. <br />Es '-......, <br />LOCYING CHESTER BOX/IrtoVE PIPE a) Se <br /> AIR ROTARY AUGER CAKE OTHER C•1-1,'"<", <br />s <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPOCATION APTO THAT THE WORK WILL DE DONE AS ACCORDANCE WITH SAN JOADUIN COUNTY ORDMANCES, STATE LAWS. AND ROUE, AND <br />RrattuarocknE of TETE SAN ATACKAN COUNTY. HOW OWNER on UCENSED AGENT'S SIGNATURE CERTVIES THE FOLLOWING: 'I CERTIFY THAT IN TUE PEPFORMANCE of THE WORK FOR WHICH <br />TEEN REFRACT 79 MOVED, 1 SI IALI. NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMMNSAlloll LANS OF CAUFORITIA." CONTRACTOR'S MMHG OR SUS-COHTRACTINCI SIONATHHE CERTIFIES <br />THE POLIES/OHO! I CERTIFY THAT IN THE PEWOINAAFICI OF TOTE WORK TOD VATICA THIS PERNITT 111 AWED, I SHALL EMPLOY PERSONS SURJECT TO WORIETAAN11 COMPINSA MN LAWS Of <br />CALIFORNIA Tlft APIUCPST MUST CALL 24 ADVANCE FOR ML MOWED man:crams AT :244f 444.34E1. COMPLETE DRAWRIO AT LOWER AREA PROVIDED. <br />,„./ ej,,r tit:- ,541:3`t twq, 61.241.e?, 11) TRIG <br />PLOT PLAN ICorimY I 1e41•1 14.1, <br />I. NAMES Of STREETS OR ROAD* MUTEST TO OR 101.114DINO THE PROPERTY. <br />OVEUPTE Of THE PROPERTY, OIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENNOITED (MUNCIE ANO LOCATION Of ALL EMOTING AM) Fnopcmo <br />STRUCTURES, INCLUDING COVEREb AREAS SUCH AS PATIOS, ONIVEWAYS, AND WALKS. <br /> <br />IF <br /> <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANINTH OF SEWAGE OTSPOIAL SYSTEMS. <br />LocATIoN Of WEU.StArrum RADIUS Of OM HUNDRED FIFTY PT, <br />014 TNE PROPERTY OR ADJOINING IMPIEFITY. <br />Socrad X 7 <br />DEPARTMENT USE ONLY <br />Psollmilan Amptml Sy_ C" 11__. <br />IrIMAMPA 81 til>12VIA ratA Date <br />OwstrlocIlen 1.-4met14,, El <br /> <br />0.. IVY <br /> <br />Pkrop InAemetten ly <br /> <br />Ele• <br /> <br />Cemmerow <br />AID/ <br />AMOUNT REFAET TED <br />FACE <br />3L-1 <br />KASH RECEIVED SY OAT <br />Pub 1-4ealth Serv. - Enviro. 173 (1/47)