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PPLICATION FOR WELL/PUMP PERM, 6"407 <br /> SAM40AOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> [Complete I <br /> APFVICAT ION PSIIERE BY MADE TOTIIE SAN JOAQUIN COUNTY Fon A PERMIT TO CONSTRUCT ANDIOn INSTALL THE WOO(DESCRIBED.TIES APPLICATION I6 MADE IN COMRIANCE WTL IN SAN <br /> JOAQUIN COUNTY DEW-OPELNT TRUE,CNAPf1ER 9-1116.3 AND TIIE STANDARDS OF SAN JOAQUIN COUNTY AIBLICHEALTH SERVICES,ENVIRONMENTAL HEALTH OIvUUON, <br /> JOB ADDRESSOR ARU_f�vvM/ 0O t4(LOA QI Pd CITY L-42ci t 1 A7F4612E/APNI <br /> OWNER'S NAME WP \ i lll/ind �Q rm c Loc& <br /> Taj ll ^� ADDRESe �.¢pp f}_jNdCe/�/�� ",ONE <br /> CONTRACTOR J-J�r ra I A m� �Q BpX r / / p/ q <br /> AODDEPS UCE/�1Z373 AIONEI 4&6 _ /{' y <br /> SUBCONTRACTOR <br /> ADDRESS UCI ATONE! <br /> TYPE OF WEILJPVMP: ❑ ""WELL ❑ REAACEMENT WELL ❑ MONITORING WELL! ❑ OTIIEfl <br /> 0 NNe 9TA1.UT r 1❑ WEll46TOEM REPAIR DEFTH PUMP SET CROSS IF <br /> REI'AIP' ❑ VAroR EXTRACTION WELL E l <br /> LAY/ +/y-EML/fcY/r/� FIRST WATER LEVEL 0 <br /> RYR OF MMPI <br /> b ege10 Pe W li I ❑ OUT OF SERVICE WILL OEORIV6ICAL WELL! ❑ BOIL RORMO B <br /> El DESTRUCTION: ��•AE l �V <br /> INTENDED USE TYPE OF WELL CONSTRUCT IOM SPECIFICATIONS A <br /> 11 INDUSTRIAL 110KNBOTTOM DIA.OF WELL EXCAVATION DIA.Or CONDUCTOR CASINO D <br /> 11DOMESTICRTIVATE ❑GRAVEL PACKNUZE I FE OF CABINOISTEELRVC DIA.OF WILL CASINO D <br /> ❑ IC MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL roMMO: ❑Y.. [IN. CONCSETE PEDESTAL SV ORILLER:❑Ys ❑NP 5 <br /> APRIOX.DEPTH LOCKING CHFUTEO BOXISTOW APE 5 <br /> AIOPOSFD CONSTRUCTION/DWLUND METHOD: MUD ROTAnV Ain ROTARY AUGER CABLE OTHEn <br /> 1 HE EBV RTIfY TIIAT IA PnEPARE0 TIIIS AI`P ECATION AND TIIAT THE WOW <br /> MALL BE DONE IN ACCORDANCE WITN SAN JOAQUIN COUNTY ONIINANCES,STATE LAWS.AND RULES AN <br /> PEGUU ON9 OF THE SAN AOUIN COUNTY. NOME En OR LICENSED AOENT'6 SIGNATURE CESTIfIE6 TIIE FOLLOWING:'I CERTIFY THAT IN THE PEIVORMANCE OF TIIE MOB(FOR WIIICII, <br /> TIIIS MIT IB ISSUE 0,1 811 LL NOT EN`_OY RSO EJECT TO WORRMAHY COMPENSATION TAWS OF CALIFORNIA.' CONTRACTOR'9 HIRING OR 6119-CONTRACTING SIGNATURE CERTIFIES <br /> ""r 11.0`MNG: 1 CERT THAT C f A CE GF TI Fon WMICII tll RMR IP I6 USD,1 BIULL EMROV E4nBONS SUBJECT TO WORIUMAHY OOMPENFATON LAWS OF <br /> CALIF CHIA.- T E T MU{ 1 V CE FOB ALL BFOURED qCOMMETE DRAWING AT LOWER AREA rz*, DF / 7 <br /> E'v_ TIO. D.'.J�AjE/_ — Y L <br /> 0.OT AAN ID...v <br /> I. NAMFP OF PRIESTS OR ROAOB NE AGE TO On BOUNOINO TIIE El10A STY. A. LOCATION OF HOUSE SEWAGE DIBroeAL SYSTEM On rnCro6EG <br /> 2. OUTLINE OF TIM FF001 ERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISMSAL SYSTEMS. <br /> J. DIMENSIONED OUTLNNFS AND LOCATION OF ALL EXISTINO AND PROMSED S. LOCATION OF WI LL6 WITHIN RADIUS OF ONE HUNDRED TIM ET. <br /> SIDUCTUDES.INCLUDING COVERED AREAS SUCH AS PATIOS,ONVEWAYS,AND WALKS. ON THE PIIOEFSTY On ADJOINING AIOPERTY. <br /> �C} G <br /> c%/ oad <br /> � � rG � <br /> 4o0 <br /> L Ynn � r ')LIMP <br /> SEP 2 6 1997 <br /> SAN:0A0 UIN CCUN1't <br /> PUBLIC HFAI TH SERVICES - <br /> 1 BNVIRCNAI°N r.L HEALTH CNISION <br /> L <br /> D"ARTMEAT USE ONLY <br /> -V A Ie. nAeeyWLAP - T- DEI• A— <br /> O�o�l lmpxlbn By DME MIE NFweWR Br '/iCll D.Iq�Y-�G [ <br /> U�nmaRen Imnxnnn er D.I. <br /> C.---O.: <br /> ACCOUNTING GHLY: AID/ FACE <br /> PE CODES PEE INTO AMOUNT REMITTED CH CK, ASH RECEIVED BY DATE PERMITISIERVICE REQUEST NUMSFR INVOICE <br /> 0 7 <br /> 3erv.-Enviro. 173(1/97) <br />