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11-05-1997 1: 55PM FROM P-2 <br />APPUCATiON FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 46&•3420 <br />NOW-REFUYDAELE PERMIT EXPIRES I TEAR FROM DATE ISSUED <br />(CcmpLt@ k Ttf ficaPtl <br />APPLKATtON IS IfERE TY LIACIE TO THE SAN JOAOUM COUNTY FOR A PIFF04T TO CONSTRUCT ANDgR WI;TAU TIIF WDfat OESCROBED. THOS APPLICATION M WADE p, COLEpUAFKE tATTII BAN <br />JOAOOW COUNTY DEVFLOPUENr T(pLE_ CHAPTER 1i-1 115_3 AND THE STANOAR09 OF SAN JOAOUSN COUNTY MOM HEALTH SERVICF9. EM'P'tO}D'FPTTAL <br />HFALTF/ OMS am. <br />JOB AOOAEQSAR APNI c <br />/ ..�-- ( c ✓J <br />• CITY y <br />/ <br />PARCEL 6tZF1AONS <br />OW7.4n-9 NAME U <br />Yr G <br />tT1�L SOVA'C£ MOVENT !RA!WCR <br />�Oo ZZ? q <br />COHTRACTOR_�' %'�eI _ �- ✓Y�r✓�c.-h <br />l �-nc <br />Aorx+Ess `�?�J Z �.t,- sr��� P�a%rc Y�'ur <br />Fisc/�19�f P„o�rF r <br />8011 CONTFLACTC' �(>G e <br />}u�-,/c <br />/ I // i l It y� { l �l <br />� AOOnW ,J Z �GI ���l.R'.< IC.I P <br />/ <br />oc, ?"OWE f / (1 , Zf <br />i-7 5") n <br />TYPE OF Wfi.IJS'U LLP, ❑ NEW WELL <br />❑ RMPLACFMfNT Y -TU <br />LYJ WNDOIao+O w[LL r (�ai2115. ❑ OTHER <br />❑ RYITAU.ATION <br />❑ WLLL ITYSTEM REPAIR <br />❑ CPO esL.O+o�CT REPAIR ❑ VAPcm E7(TRACTIOH WIE L r <br />❑ N— ❑ F—J, H v. DEPTH "Al 9u FT, FQ1&7 WATER LEVEL <br />(TYPE OF FMJIArI <br />❑ oiTTOF-SEFVICE uYELy ❑ (1EO M -VCA- WELL r ❑ 9OIL DOTVTIG <br />❑ otgrRUCT)OM <br />INTENDED LIVE TYPI Qf WF1L CONATAUr TION SPECIW-ATIONS <br />❑ I .MS -TRIM ❑ OPEN BOTTOM dA. Of WELL EXCAVATION QJ� I� VI dA. OF COMri)CTOR CAVING <br />❑ 00MESTICJPEIIVATE ❑ OftAv[,L PAc-KiwE TYPE OF CA.InMTEFLT'VC1 04A.A. OF --at.cA3Rf0 _ (_ / ✓1 <br />❑ PVBUCA.0JNIC rA.L ❑ DT4VTN oErm OF OROVT SEAL/5 TD Sf �, l . S "�;I `FS 1 / 7.> BPEc1FICAT70N <br />❑ f12ILOATIONJAO ❑ OTHER GROUT SEAL RrVA.LLED BY GROUT GRAND NAME <br />[ /AOw.To BNO <br />AP"OX. Dt7TN <br />—OM903 CONS T7tVCTTOWDIRL7JRA LMTH00: LRJD ROTARY <br />GQOVT SCAL PUMPED- ❑ Y— [IN. CONCRETE PEDESTAL tTY DmLLiR ❑ Yw ❑ p.. <br />EOCTCR73 C1¢BTER SOX/STOVE PIE <br />P <br />AIR ROTARY I�„(l o,.i ;1,AUGER OTHEFI <br />I HEoERY CERTIFY THAT I NAVE rREPAIWO TMS APPUCATTOTI AND THAT THE VIIOR( WILL BE DONE IN ACCOMANCE WITH BAN "AOUFN COUNTY ORDINANCES. 6TATE LAWG. AND RULER A. <br />MCDLATIONS OF Ttr SAN JOAOVM COUNTY. HOME OWNER OR U -E SED AGENT'S SIGNATURE CEITTIFIES THE FOLJ.OWRIG: -I CYRTTFY THAT iN THE PtfI{OPA.4ANCE OF THE V40M FOR %%"ICN <br />THIS PETY FT I9 fusuuo. 1 SHALT. NOT ci+xm0Y PER&ONB 91JSJECT TO WOOMPAAM'S CONIPENZAT10N LAWV OF CALIFORNIA.' CONTRACTOR -9 HTPINO OR VVB-CONTRAI TROD SLGNATLRiE CERT6TE8 <br />THE FOUO—IND: ' I CERTIFY THAT IFI TRfE PERFVRi/ANCE OF THE WORK FOA WNICH TW8 Pf10."T T6 Ie7VED. t eHALL WPLOY PERSO" 1TJ18.JECT TO WORgAAN-A COMPEH4AT1oN t_ALv4 of <br />CAUrORN1A�T.7'f-aPPilc AffT FATir C HOUR& M ADVAW9 FOR ALL RTGUM D f"IPTUTT_lvxA ATQwt 4AS1 s17,7. COOUVU� OMMANG AT LOWER AREA P"OV"V. <br />►LOT PkAX (D,- 1- 8-141 iiR:4t4 ' ti <br />1. NAAAEB OF STREETS OR ROADS NEAKTTT TO OR 0OVHDRIO THE ►HOPLRTY. 4. LOCATION Of HOUSE SE'WAOE 019POBA1 SYSTEM OR PROCOSEO <br />2. OUTUNIC OF TNT PpOPCn'TY- GiVTNO OVAENSIONV ANO "0" OtmcrbDN. Q-rAAIVON Of SEWAGE DtSPOSAJ- RTE'fBAe_ <br />7. OIWENODONED OVTI.JNvS ANO LOCATION Of ALL EXISTSNG AND FFIDPOSED 6. LOCATION M WELLS %%TTIUM RADRJB Of ONE MJFOCD FIFTY FT. <br />STRLICTVREJ. 04CLVOINO COV4T1E0 A;;E" GXCH AA PATPum. D4avEWAYS, AND WALKS. ON THF FMPERTY OR ADJOW+HO PROPERTY. <br />... 4444 �..........<........,............... , .. .. <br />.. ... �. 4444.._ '.T <br />4:444. <br />4444 .; <br />. W . <br />aL tn.e.+-o— ST <br />DESARTUFNT VGE ONLY <br />ACCOUNTINO OMLYt <br />AI0/ FACT <br />K COO" <br />FEE INFO <br />A/AOVNT REFAITTTO <br />CHQKf1CA1H <br />001 z <br />WEccrvLD ST <br />GATT <br />Iz s� <br />tT1�L SOVA'C£ MOVENT !RA!WCR <br />�Oo ZZ? q <br />tTTYO1CI <br />PuC. Health Serv. - Envk-O. 173 (1/97) <br />