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3-17-1997 1 0:59AM FROM. • i P. 1 <br /> APPLICATION FOR WELLIPUMP PERMIT ��fl t�IY1'�Ze1'� <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES f)Q 935^_ (�3S S` <br /> ENVIRONMENTAL HEALTH DIVISION J! <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDARII tERMIT EXPIRES 1 TEAR FROM_DATE ISSUED <br /> Popi9t9 io Trolimi91 <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PEAMfT TO CONSTRUCT ANOATR INSTALL THE WOKS(DESCM2CD-TIO&APPLICATION IC MADE IN COMPUANCE WITH SAM <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115­1—0 THE STANOAPOG OF SAN JOAOVIN COUNTY PUBLIC HEJILTIU SERVKES,ENVIRONMENTAL HEALTH OMSION <br /> ` - <br /> JOB AOORES"A APNO 3 3 AIC ac'C �/ {� <br /> 7 CITY` _ PARCLL I+ZE/A 1 <br /> bwHERY NAME ^C i I�TK f- f►�ICJIDOREso �lyl(���d �i . 5Q <br /> v ZL _ CLQ <br /> CONTRACTOR f � ,t ADDRESS p <br /> Fv9 CONTRACTOR JFK I / ADonEBF / d ocu� � A 5 .56467PRroI r �1 3 5800 <br /> �ltiF� r rr <br /> T_YOE OF WEtt,NVM P: ❑ NEW WELL Cl REDLACEMENT WELL ❑ MONRONNb WELL f ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS.CONWCT REPAIR ❑ VAPOR EXTRACTION WELL/ •/ <br /> (TWE OF PUMP) 1:1 O Pb.M H.P. DEPTH F%AAF SET Cf_ FIRST WATER LEVEL O <br /> �S <br /> ❑ OVToFv1 <br /> SEnct WELL ❑ UcoP'Y91CAL WELL• p.. 604 BOISNO Z,CPT ISL a <br /> ❑DESTRUCTION: /D /G <br /> INTENDED UBE YyvE OF WELL CONSTP:UCTN)N SOECWCAnON• ,./,, <br /> ❑ INOVSTTOAL 13 OPEN BOTTOM DIA.OF WELL EXCAVATION Z �V'FEI'�S DIA.OF CONDUCTOR CASINO p <br /> ❑ DOMEBTIC/PRIVATE ❑ORAVEL PAC MZE TYPE OF CASINGI.TE111-IM &I DTA_OF WELL CASINO 0 <br /> ❑ PUBUCAAVNICIPAL P.QfOVEN DEPTH OF OF aROVT GEAL 1Gb-4mf '71o s' 4q!TCrF0CATION R <br /> ❑ IPWGATION/AG ❑OTHER GROUT CFAL NST <br /> ALLED SY jreM,�4 GROUT 11nAN0 NAME E <br /> ❑ VOWTOM"o 1 (� ,�(/� 0ADUT SEAL PUMPED: EDy— �. CONCRETE PEDEBTAL BY OPDUFR:❑Yr Ne S <br /> APFROX.D►7TY /O1Ser-` Locxl"G CHESTER BOx'wmVE po'E <br /> PROPOSm CONSTRUCTIONAMILIJNO MCFHDO: MUO ROTARY AIR ROTARY A110ER CABLE OTNEIf <br /> I CERTIFYHR; <br /> HMSY THAT 1 AVE PKPAO TW9 APPLICATION AND THAT THE WOR(WILL Df DON%M AOCONOAwA NATN SAN JOAOUN COUNTY OROINANCE9.ATATVLAWS,AND AVLEo AND <br /> REGVLATIONS OF THE BAN JOAOUM COUNTY. HOME OWNER OR LICENSED AGENT'S SpNATUPQ CMtIFftG TH(MLLOWiNO:'1 CgKnPIY THAT M THE P11"MAANCE OP TffE V.OAL POR WHICH <br /> THIS KPOWfT IS IBOUED,f 91fALL NOT PAPLOY PERSONS XVWECT TO WR' <br /> *pUoAAS COI"'OWSA"OR LAWS O/CAUFORMA.' CONTRACTOR'S W40HO OR SV8-CONTINCTINO WONAYUfA CERTIFIIS <br /> THE FOLLOWING: '1 CERTIFY THA IN TffE PEWOAMANCE OF THE V40PK FOR WHICH TMS PERMIT IS ISSUED,1 SMALL EMPLOY F"&ONS SVR.!(CT TO WORIOYAN'S COMP"MATION LAWS 09 <br /> CALlFORN4l' f NT CALL to"OURS I"ADV[ANC9 FOR ALL o*Q%* V WSIQ ?""d&'A�T�tMI AGO-Z423- COUAnTE DRAWING AT LOWER AREA PROVIOEO- <br /> S 1i-e0. ;1�1z TIW L^�:t� L7�•c-/1,,,�.��5 f`,L--# 3�3�� D.,. 3� /`''11 <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR EOVt•IOINO THE PR0f4MTV. t. LOCATION OF HOUSE SEWAGE DOW09AL SYSTEM On MorloSED <br /> 2. OUTLINE OF THE"10PCRTY,WANG OVACH030NO AND NORTN DInECTION, LWANSION OF SEWAGE DIBPOSAL SYSTEMS. <br /> 9. D"t"GIONE0 OIJTLINF,S AND LOCATION OF ALL EXRfvq AND PROP09W S. LOCATION OF WELLS VWn N RAMS OF ONE HUNOfTW FWTV FT, <br /> STRUCTUMB,NCLUDfNO COYMO AREAS 6VC"A$PATIOS.OW4WAYe,AND WALK& ON TOE PRDP!'f{TY OR ADJOINNO PROPERTY. <br /> N� <br /> :... .....o ...:. ..Y•.. ..5.• .. .• ... <br /> �1{ e : <br /> 1 4 i.......•.i ..J .f.. <br /> C... ryY.: V...:.......• F\/fir <br /> .. ..1. i� ...i. .•....... •.y....., ....p.. Tvs .1......' ....j. J.. ...... <br /> DEPARTMIl"T WE GNLT <br /> AoPIlo.11etl 160000 ed By. Dea A­ <br /> 0,0,4 Det. fk.nTs woo-don Or Dote <br /> D—t.1, 0—I--Fe.tbn w Dote <br /> Ce.wwwgc <br /> ACCOLINTINO ONLY-. AW FAC/ <br /> FE CODES PIM INFO AMOUNT REMITTED C ASN PXMW 7f SY OAT! A ►90MIT/SERNCt REQUEST NUNS®R INVOICE <br /> 'a <br />