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APPLICATION FOR WELUPUMP PERI. .-' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION /Plj <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 WJ4 <br /> (209)458-34204P <br /> NON-REFUNDABLE PERMIT EX PINES 1 YEAR FROM DATE ISSUED <br /> (Comp1@f@ in TrIPRmlf@I <br /> AtliICATtON IS lIERE UY MAGE TO 7}IE SAN JOAQUIN COiINtY FOR A PERMIT TO CONSInUCT AND=INCIAR 111E WORK DESCRIDEO.71118 AI'PI.ICAIION IS MADE IN COMPLIANCE WI111 SAN <br /> JOAQUIN COUNIY DEVELONMENT TNI@.CIFAPTER 9-1116.3 AND IHE STANDARDS OF B N JOAUMN COUNTYPUBLIC IIEALIII SERVICES,ENVMONMENLAL 11EAtI11 DIVISION, <br /> 1O 1 <br /> JOB AOUnE8BR ANN# C,tY E -T— <br /> "J PARCEL BIZEIANN# <br /> OWNER'S NAME / ADDRESS1 i <br /> .e}14 r 1'IIdNE <br /> CONI RACI OR / // AODnEBB At5lICE,ZA�O 1Y lONE/ <br /> SUB CONTRACTOR ADOnESB <br /> IJC# PHONE <br /> TYPE OFF WELLTUmr, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITOr11P1O WELL# ❑ OTHER <br /> l' <br /> ❑ INSTALLATION ❑ WELL BY81EM REPA1n ❑ CROBS-CONNECT REPAIR ❑ VAMFi EXTRACTION W111-0 <br /> f/_.+-v I ❑Nwv�Rep.lr H.P. ` bEPTIi PVMP SET C <br /> ko, <br /> {TYPE OF MIMPI FIRST WATER LEVEL /A2,( O <br /> 1 <br /> OU1.OvBERVICE YVEIL ❑ GEOI'l1YSICAL WELL l ❑ SOIL BORING S � <br /> ❑OEBTnUCTioN: J <br /> k1. 1.1 INIENOEd Uhf TYPE OF Wit C5NSTF1I—]I N @PECIFFCATIONf <br /> it <br /> INIIUFTFMAL ❑OPEN BOTTOM OIA.OF WELL EXCAVATION DIA,OF CONOUCTOn CA8WN0 <br /> n <br /> © bOMFBTICA'IUVAfE C1GRAVEL PACKlBRE TYPE OF CABINGIBTEEtlPVC MA.OF WELL CASINO <br /> O <br /> PIISIIClAAl718CIPA1. ❑DRIVEN OEF'TTI OF OFIDUT SEAL B!'EC1FlCA710N <br /> tdA <br /> InnIGATIONIAO 110711E" GApUT SEAL INSTALLED BY OnOVT BRAND NAME <br /> E <br /> MONITOftIHG r OIIOUT SEAL PUMPED: ❑Yr ❑Nn CONCRETE PEDESTAL BY DIULLER: <br /> G ❑Yw ❑Nn g <br /> APPnOX,DEPTH LOCKING CIIES I ER BOXISTOVE PIPE <br /> PlIGP06E0 CONSTnVCTIONfM1.UNO MET1100: MUD ROTARY Ain ROTARYS <br /> AUpER CABLE OTHER <br /> I 11E'lEBY CEFIIIFY THAT I IIAVE TTIEPAPIEO 11110 MILICATION AND THAT TIIE WORK WILL BE DONE IN ACCORDANCE"III BAN JOAOUIN COUNTY OPIDI11APICE6,STATE LAWS,AND m11E8 ANO <br /> nEOMATIONS OF THE SAN JOAQUIN COUNTY, ItoME OWNER OR LICENSED AGENTS SIONk1UnE CERFIFIES TIIE FOLLOWING:'I CERTIFY TIIAF IN IFIE P'EPVORMAPICE OF T1FE WOnC Fon WltlClt <br /> THIS PERMIT IS WMAU,I SHALL NOT EMPLOY PERSONS SUBJECT TD WORKMAN'@ COMPENSATION LAWS OF CALIFOnMIA.- CONIRACTOn-S"'FUND On BUB CONIRACUNG SIONATIME CEnTITIE6 <br /> TRF FOLLOWIN EPITIFY TIIAT IN TIIE ORM E OF TIIE WOtW POR WHICH TRIS PEFIM11'IS FSBUED,I SIFALL EMPLOY I•ER80N8 BUSJECT TO WORKMAN'@ COMPENBAl10 LAWS OF <br /> CALIFORN VIE A CANT MUST C {Ip IN ADVANCE FOR ALL REQUIRED INSPECTTON@ AT 17011}4@@.yEa=, COMFLEIE b118 Nd AT(OWER RK A PROVIDED. <br /> Tb. <br /> 010—d X <br /> TBIr <br /> D.N <br /> PLOT PLAN 113,ow to <br /> t. NAMES OF STREETS OR ROAD8 NEAM PIT 10 OR BOUNOINO TIIE I'nOPERtY�NrI eo.lr le _ <br /> _ 2. dUTLIHE OF THE PROP•EniY,GIVING DIMENSIONS AND NORTN DIRECTION- 4. LOCATION OF IIOUBE SEWAGE OIOPOSAL SYSTEM On Pnorour, <br /> B. bt1AF.NBIDIJFD bUfLINEO AND LOCATION OP ALL FX18TlNO AND t7101•OBEO EXPANSION OF SEWAGE b18P08At SYNT EMS. <br /> 61 SIRUCTUnE6,INCLUDING COVERED AREAS BUC1f AS PATIOS,DMVEWAYB,AND WAtXB, S. LOCATION OF NHLLe Wlt"'N RADIUS OF ONE HUNDRED ffrTY FT, <br /> . .. PITY <br /> OR ADJOINING PnOPFRTY. <br /> .... h`'- <br /> V <br /> t � <br /> r � <br /> r a ��7 �99�y. <br /> ly <br /> c) <br /> I <br /> :. <br /> �----5 DEPART E USE ONLY <br /> C c <br /> _- <br /> p.rr Arw�-�^ <br /> nrrul lrnPnelton By O.I. P41rny In Pa ft' Bye4k <br />,IIeH _ <br /> OHS_F -•�.-!�, �� <br /> i7mdr.cll.n In.persgnn GY <br /> V. Cemmm:l.r <br /> I.141,Ir. <br />, <br /> ACCOUNIINO ONLY; AID# TACJ <br /> PECOUL@ FEE rNFD AMOUNT RIJNIITEO CHECK 1CASII RECEIVEO BY DATE PE M1f1@UTVICE REGUESt NLINBtF1 INVOICE <br /> 0� <br /> Pub-"JIM 8en. EnYire.173(1/97) <br /> 77 <br />