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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION y„n <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (G9mpM9 In TTIpS9Fnl <br /> APKOATION 19 HERE BY MADE TO THE BAN JOAWIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED.7III9 APPLICATION 18 MADE IN COMKIANCE WHIZ SAN <br /> JOAOUIN COUNTY DEVELOPMENT THLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. <br /> JOS ADOMINMA APNI 101 S. REID, LINDEN CITY LINDEN 95236 PARCEL SIZEIAPNI <br /> OWNER 9 NAMERONALD GONSALVES ADDREBsSAME rmw,462-6403 <br /> CONTRACTOR_NOACK W/O FNHW ADDRESS 4500 E. FREMONT ST 504513 <br /> ND/ PIONE1948-8817 <br /> 9US CONTRACTOR ADDRESS STOCKTON, 95215 Vee p wf <br /> TYPE OF WEUIPUMP: ❑ NEW WELL ❑ MKACEMEM WELL ❑ MONHONNO WELL I ❑ OTHER <br /> ❑ <br /> INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CPOBSLONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> SUBMERSIBLE ❑N.« w HP. 5 DEPTH PUMP SET FT. FIRST WATER LEVEL o <br /> RYK OF PUMPI <br /> REPAIRS TO ln1JIj��GPUMPIJ OUTOFSERIVICEWELL ❑ GEOPHYSICAL WhLLI ❑ wmsontm S <br /> ❑DE9TRLx:TroN: <br /> INTENDED USE TYK OF WELL CONSTRUCTION SPKUK:ATIONS A <br /> ,❑,WW INDIISTNAL ❑OPEN wTTOM ORA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p <br /> Ipl DOMESIICIWVATE ❑GRAVEL PAC ARZE TYPE OF CASIMMTEELNVC DIA.OF WELL CASINO p <br /> ❑ K1EMMUNICIPAL ❑ONVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ SNNOATIONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITONNO GROUT"At PUMKO: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLER ❑Y- ❑N. 5 <br /> AI NIOX.DEPTH LOCONO CHESTER BOXMOW RPE <br /> S <br /> P OPD9ED CONSTRIlC110N10NlIlNO METHOD: MVO ROTARY AIR NOTARY AMER CABLE OTHER <br /> 1 HERESY CERTIFY THAT I RAVE FMPAR M THIS ARLCATON ANO THAT THE WORK WILL BE DONE IN ACCOIOANCE WITH SAN"AMIN COUNTY OMMANCE9.STATE LAWS,ANO RULES ANO <br /> MGLRATIONS OF THE SAN JOAWIN COUNTY. NOW OWNER OR LICENSED AGENT'S SKINATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE KMONAANCE OF THE WORK FOR WHICH <br /> THIS KRMH I8ISSUED,I SULAM NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPFN9ATON LAWS OF CALIFONl1A-- CONTRACTOITS HIRING OR SUBCONTRACTING BIGNATUM CEMWMS <br /> TINE FOLLOWING: -1 CERTIFY THAT INTIM KRFOFVAANCE OF TELE WORK FOR WHICH THIS KRMH IB MmEp.1 SHALL ENPROW PERSONS SIISJECT TO WORKMAN'S COMIWMAMN LAWS OF <br /> CALIFORNIA.' TNF"7 FFM /H NOUIII M1NAPEDTIO <br /> IN ADVANCE FOR ALL OUIRM N9 At I30 R*TNI Etf. COMPLETE DRAWING AT LOWER AMA PROVIDED. <br /> mwr x « Y� TIB, RETAIL SALES D«. 9/25/99 <br /> Kot MN Invµ1.lk,w.l <br /> 1. NAMES Of 8TMFT8 OR TOADS NEAREST TO OR NOUNDINO THE PROKRrv. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR NIORO9E0 �I <br /> 2. OUTLINE OF THE FMPFRTY,GIVING UOAENSONS AND NORTH OBIECTION. EXPANSION OF SEWAGE pBPOSAL SYSTEMS. <br /> T. ORAEN9roNED OUTLINES AND LOCATION Of ALL FXISTBO ANO NO109ED S. LOCATION Of WELLS WITHIN RADIUS OF ONE MHUNN,FIFTY FT. <br /> STN TUREB,RICLUOIIO COVERED AREAS SUCH AS PATIOS,ONVEWAYB,AND WALXB. ON THE PROPERTY OR ADJOINING KOMRTY. <br /> V <br /> rs o <br /> i 4a <br /> y 79 <br /> 0,01s Al <br /> NOV 2 <br /> iAh .l U:iUi)1N I.I JLIIV n' <br />