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`PPLICATION FOR WELLIPUMP PERM)' <br /> SAA JAOUIN COUNTY PUBLIC HEALTH SEh CES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NOWREFUIIDABLE PERMIT 11PIRE1 1 YEAH FRDM DATE ISSUED <br /> fol <br /> APPLICATION IE HERE MY MADE TO THE SAN JOAOUN COUNTY FOA A PERAIT TO CONSFTRUCT A24pkto In 0RIMRINSTALL THE WOR(DESCRIBED.TION APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAOUN COUNTY DEVELOPMENT TrTLF,CHAPTER 0-11 15.3 AND TTH(IIC�BFANDA^R�DD6 OF MAN JOAQUIN COUNTY PUDUC HEALTH SERVICES,ENVIRONMENTAL HEALTH OMmov.- <br /> JON AOOIE/SDR APNA a I� IUn <br /> (1014CMA `1 C•� CITY PARCEEt SSIMAPR. }� <br /> OWNER'S NAME_1•TkV rn Il s1 �O ADDREBB •D.�io)[ ��', QEF]]w 7`II PHONE.(gig)fj 6 t, <br /> CONTRACTOR ADDRESS I�p�gte , PNOHEI �7 <br /> SUB CONTRACTORT ADDRESS "`'��L��"f""`III "�• rrr PHONEI <br /> TNPE OF WEWULN. &NNEW WELL ❑RLPLACUUNT WELL 14 MO—ORM WELL I IY ❑OTHER <br /> .rE9y Ri>tFPIA--TL[ATgH ❑WELL SYSTEM @SPAM ❑CROSSCONNECT REPAIR [3TR <br /> VAPOR EXACTION WELL <br /> STYPE OF PUMP; • J <br /> L/NµI,,.P 0, H.P. DEPTH PUMP SET,�`FT. FIRST WATER LEVEL NT <br /> ❑OUI-0FSERVICE WELL ❑OEOPHYGICAIWELLS ❑ SOIL MORNG B <br /> ❑DESIFMR:TION; <br /> IN7 FNaFa U4ETYPE OF WELT CONSTAUc ION SPECIMATIONS elfA <br /> 11 INDUSTRIAL ❑OPEN SOTTOM OLA,OF WELL EXCAVATION CIA.OP CONDUCTOR CAGING p <br /> 13DOME$TMMNVATE )dGRAVELPACKIMEhi pi� I� TYPE OF CAEINGIS7EEUPVC IN&DFWELLCA$rW y {A p <br /> 11 PI/SLI"UNICIPAL ❑WTVEN SR"3.V DEPTH OF GROUT SEAL SPECIFICATION R <br /> E�1.I11 <br /> ..((T(WMATIONIAO Cl OTHER GROUT SEAL INSTALLED 9Y GROUT ERMIO NAMECQ. I1 E <br /> 1Gl MONRORN6 r7nn k ORDUT SEAL PUMPED:Q(,- L_I Ne CONCRETE PEOESTAL OY DRILLER❑Yr [IN. 5 <br /> 'APP1To%.OF7IN '1[/Cyyl_• LOCKWO CHESTER NDkAROVE PIPE S <br /> PROPoIFD CONSTROCT10NICSILLINO METHOD: MUD ROTARY AIA ROTARY AUGER CABLE OTHER- <br /> I HEREBY CtKf"THAT I HAVE PREPARED TMS APPLICATION ANO THAT THE WDFK W U ISE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OPONANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN CDUNTY.NOLLE OWNER all UCFNSED AGENT'S SIGNATURE CFRrWMI THE FOU-0WFW:'N CERTIFY THAT IN THE PERFORMANCE OF TINE WORK FOR wN CN <br /> THIS PERMIT It I21L1ED,I$HALL NOT EMPLOY PERSONS OUBJECt TO WOIIMMAN'1 COMPENBA7TON LAWS OF CALIPOFE'SA.'COMPACTOR'S NRINO OAUM- <br /> SCGMFVICTIM7 SIGNATURE CEMWIEI <br /> THE FOLLOWINOI '1 CERTIFY TH T N THE PERFORMANCE OF THE WONL FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORMCOMPETISATION LAWS OF <br /> GN <br /> CALFOIA.' INF NT M ST CALL 24 HOLM$IN ADVANCE FOR ALL REOURED INSPECTIONS AT R2OSI�{p.14S1,COMPLETE DRAWING AT LOWER AREA PGOVIVED. <br /> P -R L4 D.L. 1 <br /> ROT RM <br /> I.NAMED OF STREETS OR AOADI NEAREST TO OR BOUNDING THE PROPE1UY. 4,LOCATION OP HOUSE SEWAGE DISPOSAL SYSTEM OR"lopoSED <br /> 2.OUTLINE OF THE PROPERTY,OMNO OrMENWONS AND HORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYOTEMS, <br /> 7.ONMEN/1ON.ED OUTLINES AND LOCATION OF ALL EXTSTINO AND PMOOOSED 1.LOCATION OF WELLS WITHIN RADIUS OF ONE NUHORrD FIFTY FT. <br /> STRMTLMS,INCLUDNO COVERED AREAS OUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON TILE PROPERTY OR ADJONINO PPOI4RTY. <br /> 11c ► <br /> DEPARTMENT USE ONLY <br /> Applk.U.RA WIW Ey:44 <br /> G,p Mrw14n <br /> O.I. <br /> D..IOSIMn p+P-I-BY <br /> O.r. <br /> C—A.: <br /> ACCOUNTING ONLY; AIDS <br /> FACS <br /> FE CODEI FEF INFO AMOUNT REMITTED C ICAIN RECEIVED or DA E P@ROTrSIRVICE REOU"T NUMSFTI INVOICE <br /> So � o fo a o <br /> Pub.HeaAh Serv.-ErMro.173(1/97) <br />