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11 -OS -1997. 1:SSPM FROM P_2 <br />APPLICATION FOR WEWPUMP 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 />NOW-REFUROABLE PERHIT ExPIRES 1 YEAR FROM DATE ISSII <br />( =Vlom FA Triplktbl <br />APPLICATION 16 IfERE SLY IAADE TO THE SAN JOAO(IM COUNTY FOR A PEFD.6T TO CONSTRUCT AN=Ft INSTALL THE VMFK OESCFSBED. TUM APPUCATION IS :AADS M COMPLIANCE 1MT1I SAN <br />JOAOUW COUNTY OEVELOPMEJYT TITTF, CHAPTO( 9�-1 1� 1 6-3 ANO THE 6TANOARD9 OF SAN JOAO" COL/NTY RJBUC HEALTH SERVICES. E ENTAL HEALTH OMeaON_ <br />JOS AOMSSOA APW I TIBC. <br />r �.. <br />j <br />❑ tNOUSTNQAL <br />17s <br />1 cT F't r <br />CITY (, [�c� <br />PARCEL 6Q/APHS <br />OWNER'S NAFAE <br />TYPE OF CABAiOJLTEfL)rVC /' f�✓ L- <br />AiDe"ES9 <br />PHONE r <br />CONTRACTOR y ��n <br />c.-/�j�/�,../i / �1'1 <br />y 7 <br />Jc r� �rI AOOR S94— �/ <br />�) /,. '} <br />f�i/7 LK r��1H9 ; rxOYE r`7 <br />1 <br />Bf/e CONTRACTOR ' S C_C.f, CT e- <br />` , r I �' C CGrI_J <br />j'-ll•✓'i> <br />_ADORStE i/ / V {���7C�.� <br />X16 /'51'ell)v'9I <br />/,�1�/i�'.� <br />Ir/ K/_I UC�PFONE f / /(J-['�[,' /Z 76 <br />GROUT SEAL PJPPED- ❑ Y.. ❑ N. <br />CONCRETE PEVESTAL. BY DNOLLEI! ❑ Y.. ❑ Nu <br />APFROX. 0I7TH ! /4L <br />TYPE Of Wt1A/R AAP; ❑ NEW WELL <br />❑ REPLACEPAENT WILL <br />❑ mawroRafO WML r <br />❑ OTHER <br />❑ INSTALLATION <br />❑ WELL SYSTEM REPAIR <br />Cl CROSSCOEeNECT REPAIR <br />❑ VAPOR "TRACTION WI;u r J <br />❑ Nw. ❑ P -,.J, N.P. OEM" PUMP SET FT, FIRST WATER LEVEL <br />R YPE OF PUMPI <br />❑ OvT'OF-SERVICE WELL ❑ GEOF",=At WELL ♦ ❑ Son. Doi NO <br />❑OEs-mvc- oN:-- <br />INTENDED Ul[ <br />TY9Ni QA WELL <br />CONATIf TION lPEC74CATI0NL <br />RECOVF0 tT <br />pk <br />❑ tNOUSTNQAL <br />❑ OPEN 60TTOM <br />ORA. Of WELL EXCAVATION11Y1 <br />0". OF CONDUCTOR CASINO <br />❑ OOME6TR'./.VATE <br />11ORAVEj PACKIVZC <br />TYPE OF CABAiOJLTEfL)rVC /' f�✓ L- <br />09A. OF WnL CA$LNO _ Z in <br />❑ PUSUCAAVMCMAL <br />❑ OIVvSH <br />r <br />OEITIN OF OROVT SEAL I , -+o - 1 <br />SPECIF"rATION <br />❑ IRRIGATIOWAG <br />❑ OTHER <br />GROUT VEAL WIMTALLM 6Y <br />GROUT 6RAMD NAM! <br />® MOwTORSNO <br />GROUT SEAL PJPPED- ❑ Y.. ❑ N. <br />CONCRETE PEVESTAL. BY DNOLLEI! ❑ Y.. ❑ Nu <br />APFROX. 0I7TH ! /4L <br />. <br />LOO(RJIO CWSTER 60XlSTOVE PY'E <br />NELWRO W9TNOO; WM MTARY <br />PROFOLED CONLTm=Tro(D <br />O <br />AIR RTARY ('�TI� <br />OTHER <br />I HVREIFY CERTIFY THAT I HAVE PREPARED TM9 APPLiCA.TION AND THAT THE WORK VALL BE DONE M ACCORDANCE WITH SAN JOAOURI COUNTY ORDMANCEQ. STATE LAWS. AND RULES ANO <br />REGULATIONS Of THE SAM JOAQUIN COUNTY_ NOME OVJPIER OR LICENSED AGENT'S StGMATURE CERTIFIES TIfE FU(1OVANO; I CERTIFY THAT IN TME PEWORIAANCE OF THE WONC FOP W7f1CN <br />?Mfg PEPA41T IS f69UE0. I SHALL NOT EIZMOY PERSONS 9U!&XCT TO WORIWAM'L COSAPO49AT10N LAWS OF CALIFOFIaA.' CONTRACTORS HIRING OR LU6CONTRACT003 SSGNATURE CLKE WMfl <br />THE FOLLOWING: ' I CERTIFY THAT *4 TTfe POWOPUANCE OF TUE WORK FOA VAOCH Tlrte PEFOXT IS 16eUE0. I BEAL.0 17APLOY PERSONS SVSJECT TO WORIDAAR'S COMPENAATION (AwV os <br />CAL1rORN1A.' THE APPUCC/AAMTT MV%T CML 2A HOUPA 04 AOVA*K!9 FOR ALL REOVARED I %PIPC"ORA AT Dr04" 4"-2427. COWUM ORAW(NG AT LOWER AREA PROVID <br />>ED. <br />elo.�a z--� Tnr. �r'r- -; c"� D.*._ l LD - Q O <br />PLOT /LAM 0>—to S. -W Saw ' f11 <br />1. MAAAE6 OF STREETS OR ROAOS NEARETTT TO OR DOL1N01N0 THE PROPERTY. 4. LOCATION OF NCKM SEWAGE DISPOSAL 6Y9TEM OR PROr06E0 <br />2. OUTL04C OF THE POOP£RTY. GIVING OWEHSKY" AND NORTH IXRECTIO41- p(DAA1mm OF 6EWAQE ONSPOSAL 6YS'TBAL_ <br />7. ONMENOONED OVTLOtF,S ANO LOCAT10" OF ALL EX19TTNO ANO PIIDPOUED 6. LOCATION OF WEILA WTTT-M 7ADR79 W ONE M!►U4ED FST"/ FT. <br />STR(JCTUrMS. V+CLVOtNO COVERED ARMS WiCH AS PATIOB. U RvXwAYS• AND WALXS, ON THE P OPfRI V OR ADJORCHO PROPER". <br />SF...A�.Ta4<Na... n'tnp .......... <br />b9ART"94T TRE ONLT <br />Owf yMw i—r- 61 <br />—.I. OIR Yr I ADS I FAC/ <br />. Q• <br />oa- AtO�V� 1 <br />On• <br />Pub. Heatth Se(Y. - Envko. 173 (1/97) <br />FEE WPO AMOUNT REFIRTTED <br />em"WICAAH <br />RECOVF0 tT <br />pk <br />OATS: <br />/2 coo <br />FWWA 989tVLCf FXaU T NUIM9R V(VORC[ <br />r,"ozz7�FZ <br />K coo" <br />Pub. Heatth Se(Y. - Envko. 173 (1/97) <br />