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3-17-1997 1 0:59AM FROM 0 0P. 1{ 1 APPLICATION FOR WELUPUMP PERMIT �� Kk4zer- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES s( 0 ENVIRONMENTAL HEALTH DIVISION 0 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209)468.3420 M-REFUNDARLI PERMIT WIRES 1 TEAR FROM DATE ISSUED (Comploa h Trlpliketol APPLICATION IB HERE BY MADE TO THE HAW JOAOUIN COVMIY FOR A PE9WT TO CONSTRUCT ANO)OR INSTALL THE WO1K DESCHIBED.TIUS APPLICATION IC MADE IN COMPLIANCE 1MTH SAN JOAQUIN COUNTY DEVELOPMENT TRIS.CHAPTER 9-1115.3 AND THE STANOMepg OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEItVICEG,ENVIRONMENTAL HEALTH DIVISION. JOB AOORESS/OR Arra+ LC CITY LjtpcL 6&- PARCEL•+2FJAPNf OwNER'6 NAME 1? L / U114tC -AFBs oo uQ_�p H �l/ RcoNE f�r SB�8�Z r - ztGl W�b•Jfr!Ic .I CONifiAGTOR rDLt_ .. G1.1.0.Ile ide c�V�—GJ�y�er�Pu&- �AOD�e■s �^Q�&L-1-4 Ucr l4a •_�l�-9b�QS/�/� gm CONTRAGrOR G7 — y1,LL ^Dome& 960 T L DWe R L, 1766M-07 QW 3,�- z TYPE Of WlElit1PLIMP: ❑ NEW WELL O M'LA EMENT V4u ❑ MowroIVHO WELL• ❑ OTHER ❑ INSTALLATION ❑ WELL ff"TEM REPAIR ❑ CROSS.COMNECT REPAIR ❑ VAPOR EXTRACTION WELL• ❑New O p..4' N.P. DEPTH K^dp SET cT_ HAST WATER LEVEL p (TYPE Of➢IJMP) ❑ OVToaBERVIcE WELL ❑ GEOPHYSICAL WELL• X Boa ItoR. (-75 ❑DESTRUCTION- :Lee INTENDED USE 72I-ELL COPAPECWCAnON& A ❑ INDUSTRIAL ❑OPEN BOTTOM dA.OF WELL EXCAVATION CIA.OF CONDUCTOR CASINO. p ❑ DOME STIC)PRIVATE ❑GRAVEL PACXn9ZE TYPE OF CAS..01STERIPVC_ t4 IA . CIA.OF WELL CA'ING p ❑ PUBLICnAVMCfPAL 0DIaVEN DEATH OF GROUT VEAL IDD fb ..Ft_ 81`E'CIFICATION R ❑ IRRIGATIONIAG ❑OTHER CROVT SIAL IMSTALLED BY GROUT GROUT BNWO NAME E ❑ VOWTORINO � OROUT SEAL PUMPED: ❑y— .4Ne. CONCRETE PEDESTAL BY vmiEn:❑Yr JKNo APS PROX.DP / TM t0cmN0 CHESTER SOXATIOVE PvE S PQOPOSED CONSTRUCTIONIDAUINO METHOO', MUD ROTARY AIR VOTARY AUGER CABLE OTHER X C,-n, - 'mac �> HEREBY CERTIFY THAT 1 HAVF Pt�PARO THIS AP AND THAT THIf V.V"(vvv"SE DONE M AQCOh3ANCE WITH SAN JOAOWN COUNTY ORDINANCES,STAT!LA S,ANO RULES AND nEGVLATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT?SIONATURL CdITIFITis THE POLLOV404:'t CUITT1fN THAT M YHE PFRIORMANCE OF TffS W01R POR WHICH THIS PERMIT IS ISSUED,(SHALL NOT DAPLOY PERSONS sUOJECTTO WORIOMAR'S COMPW$ATION NWS OF CAL/PORMA.' CONTfLACYOR'S OMMU OR SUS40NTRACYING SIONAYURE CERTrSfO THE FOUOWwO: '1 CERTIFY THAT IN TtfE PERFORMANCE OF THE WOIK POR WHICH THIS PEWIT IS MOVED,1104ALL CfAPLOY PERSONS SVSJECT TO VMRN MAIi'S COMP61414ATION LAWS Of CALIFORNIA.' C T CALL/2A H��Oy.U.�RS IN ACVANCtI FOR ALL IIMUWUD INSI/i�"O"Ill AT tNGI 44--�tU. CO�YP6ETE VRAWNQ AT LOWER AREA f4%O/1 XD. Bbl�d t[.C1 F 1 NTZ � TRI■ leC C��L'` PLOT Pa,w IOr—m Sed■9 Se.l.�_ - 1. NAMES OF STREETS OR ROADS NEAREST TO OR NOVNDIMO THE PROPERTY. A- LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on rYOrOSED Z. OUTLINE OF THE PROPERTY,GIVING DIINFMSIONS AND NORTH ORIECrION, EXPANSION OC SEwAOF,DISPOSAL SYSTEMS. 9, DIMENGIONEO OUTUNF,S ANO LOCATION OF ALL EXnTTV C AND POOPOOM S. LOCATION OF WELLS%WrMN RAMP OF ONE HUNDRED FIFTY FT. STRIICTUIa;s,RICLUVMQ COVERIO AAX.AB SUCH AS PATIOS.OWVL WAYV,AND WALXG. ON THEPROPERTY OR AD_f0*4 N0 PROPERTY. .1.... ... ..r. rF. �I.1I1r1rI.!�.......... .. N : . .... OI S�� T :. ... :. ::::. .�.{]�. t�.l ..:... .. :: ?5. . .... t .. °.�.ft'7 .. .. ..... DaARTrAmr Use ONLY �j J AoPQ■■twI Aee.etwd BY Date �O l A,— Grout ln■Nc1f■n Sr pes Ptane L-OP-1100 Sr Dom P..I...■u■I.I.�p—tion SY Del■ Gewwlenl■: ACCOUNTING ONLY. AILH FACT PE CODES FEE MFO AMOUNT RpWTTEp MASH ItBC/gVED BY p PM"T/AFYr VM%REQUEST NUMS®t INVOICE