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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC IIEALTII SERVICES <br /> ENVIRONMENTAL IIEALT14 DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95ni-m <br /> 1109► 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FRDM DATE ISSUED <br /> APPLICATION IS HERE RY MADE TO 111F SAN JOAOUIN COUNTY ron A PERMIT TD CONSTnl1CT1AND/On11NSTA1l TIIE WoW bFRCMnEO.TWO AM�LICA710N IS MADE IN COMPLUNCE WRII SAN <br /> JOAOUIN COUNTY DEVELOPMEENTT-�1TITLE,CIIAPTF.n B-1 115.3 AND TIIE STANDARDS Or RAN JOAOUIN COUNTY 1"URLIC IIFALTII SERVICER,ENVIRONMENTAL IIEALTII IN COpII, <br /> JOB ADOnE88/On APNI S /'0 S, ��f� <br /> ���C�C7�' CIT'I <br /> OWNER'S NAME [_//.. J PARCEL SIZE/Ar-140 <br /> ADDIIFRR :9%7 S. <br /> CONTRACTOR �� / � PHONE 4;2 ^/(v 14K <br /> GmnbnrnnLIC C{/7 MIONE♦ <br /> Bve coNTRAc7on 4 W <br /> nnDnraR q All <br /> TC#__- ---MIONE <br /> TYPE OF WELL/PUMP; ❑ NFW WELL ❑ nfPtACFMFNT WELL ❑ MONII OnINn WELL A <br /> OTNFn <br /> ❑ INSTALLATION ❑ WELL SYSTEM nrPA,n ❑VAPO <br /> ❑ CRORB�CONNFCT REPAIR ❑ VAPOR EXTRACTION <br /> ❑New❑ WELL/ J <br /> Itepdt ILP. DFp111 PUMP Sf.T FT.RYpE OF PUMP) <br /> DVT-OF-SERVICE WELL ❑ FIRST WATER LEVEL O <br /> OIOPI IYa1CAl.WILL I <br /> OOII nonlNO e <br /> L]DESTRUCTION! <br /> INIEHDE <br /> 'USE 1YPE OF WELL CONSIRUC 110N EGFICAIION_e_ <br /> ❑ <br /> INDUSTRIAL ❑OPEN BOTTOM bp <br /> �� A <br /> ❑ <br /> ❑ DOMESTIC/MBVATE ❑ DIA.OF WELL EXCAVATION onAVFL PACKIRIZE -- DIA.Or CONoUCTOn CASINO D <br /> /'UBIIC/MVNICIPAL ❑bRIVEN lYPr Or CASINO/STrrl/pVC DIA,OI WILL CASINO � <br /> DrPTII OF onol/r RF.AL SPECIFICATION e— / I <br /> ❑-, I��RRIOA710N/AO OTHER GROAT 6FAL INSTAL LFD aY A <br /> w MONITORING / Onol/T BRAND NAME E <br /> r � 5- 1 OnoUT SFAL PUMr4 ❑Ye. IJ Ne CONCRETE hEOFBTAI BY DRILLER;❑Y�r <br /> APPnO X.DEPTN 0 e S <br /> LOCKOTO CHESTER BOX/ATONE Mf`E ' <br /> PROPOSED COH67RVCTIONIDPoll1N0 MET NOD; MUD ROTARYS <br /> Ain ROTARY AUGrn CARLF. /] <br /> OT{IFR 1p /1y,,.� <br /> 1 EGULAY CERTIFY TNAS 1 HAVE MIEPARFO THIA 10"F OWNER <br /> AND TIUT TIIE WORK WILL BE Do NE IN ACCORDANCE VAIN RAN JOAOI/IN COUNTY OMINANCEB,BIATE lA'WBz`,A-NO nULEa ANO <br /> nEQUlAT10N8 OF TIIE SAN JOAOIIIN COVNTY, IIOMF OWNER On LICENSED AOFm t'n SInNATUnF CFRTIFIFR THE FOLIOMuo:'I CFRTIFV TIIAi INTNF PI nIORMANCE OF TIIE WORK FOR WI RCN <br /> TNIS PEnMIT IS ISSUED,1 BIIAI L NOT EMM.OY prnRONB BUSJFCT TO WOnXMAN'S COMPEN RATION LAWS Or CALtronNIA.- CONTRACTOR'S NIRINO OR RUB COUTFXACTINO SIONATURE CERT IrlEB <br /> TIIE FOLLOWING; '1 PCERTIFY <br /> CAN THAT IN TIIE PERFORMANCE OF THF WORK L n WNn_E TIIIR T'fnMrT 18 ISSUED,1911ALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT FAUST CALL 24 FLOURS IN ADVANCE FOR ALL nEOURFD INSPECTIONS AT 12001488-3422. COMPLETE DRAWINO AT LOWER AREA PRO+V�ID/E//Q,. /9 <br /> -��910—d XBG T111e (15—�/057yj 2-' <br /> NAMES OP STREErB OR ROADS NEAREST TO On ROUNDINO TIIE rYMOF'rn TY}tndd Rer.le •Ie <br /> 2. OUTLINE OF TIIE PROT'FRrY,OIVINO DIMFNRIONB AND NOnr11 DIRECT ION, 4. LOCATION OF NOUBE SIWAOE DISPOSAL BYn1EM On Pnoro BED <br /> a. DIMENSIONED OI/TUNFS AND LOCATION OF ALL EXISTINO AND FTIOPOBFD EXPANSION OF SEWAGE DISPOSAL SYSTrMB, <br /> STRUCTURES,INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, B• LOCATION OF WFLLB WTTNIN RADIUS OF ONE HUNnnED FIFTY FT. <br /> ON THE FYMOptnrY On ADJOINING M)OhFFTTY. <br /> t <br /> !j 11.K DFPAnf MFNT USF,ONLY <br /> APPllaellen Aeeepled By <br /> Grout Irnpetllon by Z? <br /> De1e I\m1P Irnpn:llon By <br /> beNeuetlon lrnp .Ilon Dy <br /> 0.1 e <br /> Cemmerd.; <br /> Bete <br /> 6 .5• Z -7 <br /> I -- <br /> ACCOUNTING ONLY: AIDE <br /> rnc,r <br /> PE CODES rrE INTO AMOUNT nOMITTEtl CIIFCKI/CAAN nrcnvr.O By DATE <br /> ---•—� PERMIT/e FRVICE REOLIEST NLMNM <br /> Lab— <br /> INVOICE <br /> Pub.Health Serv.-Envim 173/1/0al --- <br />