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.... ... <br /> E1 <br /> � f,Y755ys � <br /> APPLICATION FOR WELL/PUMP PERMIT A <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 55202 <br /> (209)458-3420 <br /> •1 <br /> lan-REFUDDADIE PERMIT EXPiAE!1 YEAR FROM DATE ISSUED ' <br /> ;:;� IGMgININ M Tr4Mul f; <br /> _ APPLICATION IS HERE By MARIE TO THE SAN JOAoM COUNTY MR A PERMIT 70 CONRTRUCT ANDIOR INSTALL THE WOW OEECRINEO•TIOe APPLICATION IS MADE IN COMPLIANCE wryPI BAN <br /> JOADUN COUNTY DEVILOPMEIIT TITIN CHAPTER 9.1115.3 AND THE STANDAIUN OF SAN JOAOUIN COUNTY PUMRC HEALTH SERVICES.ENVIRONMENTAL HEALTH OMSION. I: <br /> Joe�bbE�eerpnAPrl!_testa Gtr / '_jam i <br /> CITY PARCEL BI2EIAPN! Y: <br /> ONTIFR'E NAME ADDRESS � <br /> ADDRESSy� `r TMO.R F q 1'• <br /> --- COMRAeIpEI�dLI_LA�� L am- ADDRE..j�o e /G f'S UC �+VNgNE. '.'C}j'V- <br /> SUM CONTRACTOR ADDRESS 7JC! PHONE/ <br /> j TYPE or RIE mymp1 ❑NFw WELL I]IErLACEMENT WELL ❑MONTTORI M WELL! ❑OTHER <br /> -�:.�{ ❑NsfAllAigN [3 WELL SYSTEM REPAIR ❑CnO8S-CONNFCT REPAIR - ❑VAPOR EXTRACTION weLL I, J <br /> OHw'r❑RIP.Y H.P. <br /> (TYPE OF PN DEPTH PUMP SErFr. FIRST WATER LEVEL1�.,/7C� p <br /> FRPI <br /> �T - <br /> -C�OUT-0FMERVICE WELL ❑OEORIYSR:AL WELL F ❑ BOR SOgHO <br /> ❑DESTRUC7gH. [+ <br /> 'jNTENO[D ■ im— CONN TION■FECIPCA Na I, <br /> A <br /> ❑INbUETNAL ❑OPEN BOTTOM DIA-Or V/ELL EXCAVATIONJ <br /> SIA.OF CONDUCTOR CASINO p G' <br /> ❑T1OMEa7CRNVATE ❑GRAVEL rACIVaDE TYPE OF CASINONTE[LRVC SIA.OF WELL CASINO p <br /> •'"3 +WPINUCAUUNICIPAL ❑DnMN <br /> DEPTH OF GROUT SEAL SPECIFICATION <br /> ---:.; ❑11WOATgNIAO 13 OTHERIf <br /> OROU7 NEAT.NSTALLED eY OPA117 BRAND NAME F Fj <br /> ❑MONITOIaNa ''7GROUT SEAL PUMPS;[IV- ❑N. CONCRETE PEDESTAL BY ORSUK-❑ [IN.N. S F <br /> ArPROR.ovTN /!,G 4CAr - Lumum CIMOTER MoxMTOVE PIPE S <br /> . / <br /> MOPOBEO CGNSTRUCTIO 1ALLINO MEIHOOI MIN ROTARY AIR ROTAITY AUDL11 GAME OTNFR <br /> I IPFgeY CERTIFY THAT I HAVE PREPARED TPe APPLICATION AND THAT TIRE Wo1u WILL NE DONE IN ACCORDANCE WITH MAN JOAOUNI COUNTY ORDINANCES.NTATE LAWN.AND RIMES ANS <br /> �--- MOULATIOHS OF THE SAN JOACNNH COUNTY.HOME OWNER ON LICENNFO AGHIT'e 1gHA7URE CTRTR'IEM THE FOLLOWINSI•1 CERTIFY THAT IN TREpENMNLIANCE OFTHE WORK POR WHICH <br /> THIN PERWT IS ISSUED.I NIALL HOT EMPLOY PERSONS SUBJECT TO WOMEMAN'B COMPENSATION LAWS OFCAUMPMA-•CONTRACTOH'a HIMNM ofteua-CONTMCTSM NgHATV E CENTNRM <br /> THE FOLL YANG: '1 C[iRIFY THAT N71IT PEItORMANCE OP T11E WON[FOR N111CN TMe P'EIIUIT IS RSVEp.T NI TALL EMPLOY PPAsaNS W <br /> BRCT TO WOIINNIAN'e eeMrE11{ANON LALLM OF <br /> CAHFOPIIA.- TI CAVI MUaT DAl>M H*Me N AMOAT1CM FOR ALL NBOUIRED DurNO71ONe AT PSq 422-94".COMPLETE ORAWBIO AT town AREA PROVIND. <br /> ,,p9 <br /> PLOT PLAN IO!•..1.S.NW%.I• Ie <br /> 1,NAMES OF STREETS OR NOADB NEAREST TO OR BMMDM THE PROPERTY. A.LOCATION OF HOUSE BEWAGE 016MVAL SYSTEM On PIIoromEo <br /> !.OLITLNE OF HROPERTY.GrVMq DoWIMMONN ASID NORTH DMECTMN. EXPANSION OF SEWAGE blNP DM SYETETAS. <br /> DMQI�ONEO=LINES AND LOCATION OF ALL 1XISTRIO AND PIDPO{ED 1.LOCATION OF WELLS INTTISN NAONH OF ONE HUNDRED FIFTY FT- j <br /> y{ STRUCTUIEM.NCLUIANO COVERED APE"BUCK AS FATIOM.OMVEWAYN.AND WALKS, ON THE PROPERTY OR AUMIN M PROPERTY. <br /> f ] <br /> I rr, <br /> ...... ...... r.. <br /> :. :.. <br /> I' - <br /> .1 <br /> �1 I: <br /> VS <br /> VIE ,� <br /> _ c . <br /> .. <br /> ..i........... . <br /> I <br /> i <br /> 1 by ENTum" <br /> 0 IF Z� <br /> APPII..II.n A—p..d b L <br /> -- G'.w 4.P.N0n Mf On• P1n.P hi.P�R1vn eT ^ F - <br /> bN• <br /> '� pwbinll.n 1l.P�IIsR BT - l�7 <br /> --- AECOVNTING ONLY. AIO! FAC! I` <br /> -" r!COp[a FEE IrIPo AINOVIITTTTO C C ANN RFCBVED NY DATA FMMBTINERVICE REOUENT NUNMNI INVOICE <br /> 3IqI6 azq ' <br /> S <br />