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1 <br /> APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES MELS f7-ti n �, <br /> f Ulf �., ENVIRONMENTAL HEALTH DIVISION t <br /> LL � Y�oa EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> l101f•REFpMDABI#PERMIT ERFIRES 1 YEAR FROM DATE ISSUED COPY , <br /> AMICATION is HERE nY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONNTMOCT'ANnfult WRTAtt THF vMRK DESCRIBED.THIS APPLICATKO14 is MADE IN COMt�l1ANCE WITH SAN <br /> JOApUIN COUNTY DEVEIOPM�Efry�(T TITLE CH ER 11-1115.3 AND THE STANnARDB OF BAN JOAOUIN COUNfY IV IC IIEALTII SEnMEB•ENVIRONMENTAL IIEALTII DIVISION, <br /> JOB ADnMsslOR APN# C! �A � `r CITY /�F <br /> J� - (�1 VAI PARCEL R17_F.IAPNI <br /> OWNER'S NAME ` I. /} ADORFAR J <br /> CONTRACTOR L �/ � //.� '^ kdot q f'►RfT7E.3 .+ J Z <br /> AMNTER9 a`£ ., .,.�IIe• J I , IrltlNe F <br /> aU0 CONTRACTOR ADOMR9 LK:# <br /> �-yy�� // i'HONE/ <br /> lrYPE.or WELLIPUMP; Ir{,0 WELL ❑ REPLACEMENT WFLL Cl MONRORING WELL• D OTHER <br /> �w 1 [I MBTALLATTON ❑ WELL BVaTEM Ain ❑ CROPS-CONNECT nEPAIR © VAPOR EXTRACTION WELL A` <br /> _�L !rl�'h— J <br /> ❑N.wI]Repdr H.P. DEPTH PUMP BET FT. Finst WATEn LEVEL <br /> {7 VPE OF PUMPI �ry•y y t, <br /> OUT-0F,0FRWf WELL 0 amMIVRICAL WF[L# I] BOIL Soma <br /> [J bE BT RUCTibN� <br /> INTENDED-ULE TYPS OF CON/TRUC ION SPECIFICA IOl'L/ � r W" <br /> �❑ IIIDUSTIRpL �❑70O BOTTOM MA•OFWFIL tXCAVATIOH btA.OP CbNhtICfOIf CAa1Nb_ 'Sr <br /> Il�;-fi"00MESIICRYBVATE I.:J[!RAVEL PACXMIZ£ TYPE OF CAa1NO1sf EFIJpvC_A�W DIA,OF WELL CASINO n <br /> I--1 PURLICIMUMCMAL ❑nTBVEN o <br /> DEPTIF OF 011018 REAL LPECIFICATIOH �� ,� � A <br /> ❑ trtMOATION/AO 0 OTHER aROUT.REAL I"aTAl1ED By I. <br /> FFL GROUT BRAND NAME f�-'712, F <br /> © MONITORING GROUT BEAL"PUMMM. [J,Lx.a ljNa CONCIIETE PEDESTAL BY Mtj Fn: tLyI+FlIL`�'I]Ne s <br /> APPROK.DEPTH LOCKING CFK:SIER ROXAfTOVE PIPE <br /> PROPOSED CON/fgLK:TONlbroLUNO METHOD; MUD ROTARY AIR flOfARY AUGER CABLE OTHER N <br /> lr("7_�1 S <br /> 1 IIEAEBY CEnT1►Y THAT T IIAVE PREPARED THIN APPLICATION AND THAT THE WOOL YNLL BE DONE IN ACCORDANCE NAT"SAN JOACKM COUNTY ORRIHANCES,STATE LAWS,AND RIII.Fil ANO <br /> nFOWJLTIONS OF THE SAN COUNTY. NOME OWNER OR LICENSED AOENT'9 St0"ATUM CIPWIFIES THE FOLLOWWO,'1 CERTIFY THAf 04 THE PEITFORMIWCF OE THE VWgC FOR WHICH <br /> 1111""FtM1T la IRRUED,I IAI.L"OT OY PERSONS MMJFCT TO WORKMAN'S COMPEHSAT1oN IAWS OF CAtIFOTTPSA.' CONTRACTOR'S IRRNTO OR SII&CONTRACIRM mONATLMF CERTttits <br /> ?Hf Irmo CE IFY THAT N pow RMANCE of TILE WORK Fon%%it if THIS R IN <br /> ISSUED,'I"HALL EMPLOY PERSONS RURJECT TO WOR7tlMAN'S COMPENSATION*A OT <br /> CALIFORNIA T• AN M T A S IN ADVANC/FOR Ail RE=IM Nll T( 1 '�}A�7, COMI<ETE DRAWING AT LONrtp AREA PROVIDED. <br /> Blared X Thle '\ <br /> D.i. <br /> PLOT PIAN Moo-to mewot aa•le 'M <br /> 1. NAMES OF Ot"[FTS OR ROADS HEARFBT TO On BOIIHMM THE PRDPERTY. A- LOCATION of HOUSE BIWAOE DISPOSAL SYSTEM On T'IIIH'OBEb <br /> Z. OUTLINE OF TIFF PROPERTY,OIVMKI DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWAOF(RRPOM SYSTEMS. <br /> 3. DIMENSIONED OVTLINEe AND LOCATION OF ALL EXIBTINO AND PROPOSED S. LOCATION OF WELLS IARTNW RADIUS OF ONE HUNDMI,FIrTY FT. <br /> STRUCTURES,IAICLUDINO COVEITED AREAS SUCH AS PATIOS,MSVEWAYA,AM WALKS. ON THE PROPERTY OR ADJOINIFIO PROPERTY. <br /> � - <br /> � i <br /> . � <br /> A.,,; <br /> l- <br /> ;.. <br /> �rovlllt_�;�r,.,f� .�;�� ,:�r>•r>llvlr �;, : . <br /> OEFARTMEfiT USE ONLY :... <br /> '"-ApplleNlen AeeipleA By�aF '-+." _ L,. ,-T --•ate.,. . ,�__ --..s�v.I�.ts. / �/ � ` _.'."'-�'"'•' <br /> Oreltl Impeelten BT_,� .` .- •K naa .. r%—p Inreeetlnn 18► ...'. hIH• <br /> he•I,tlellen I.wper.Ilen Ry ; <br /> CemmwN•:_ <br /> ACCOUNTING ONLY; AID# FAC/ - 11 <br /> PE CODER FEE INFO AMGUPIT M MITTEb TIEC ABH REC6 SY RAT PETTMIFISERVICE REOIIEBT NTJMBIEt INVOICE <br /> 13. (X's 0-3 Orr& ` c yD <br /> �b -'v o 19(-0s <br /> Pub 'leallh Serv.-Envito.173(1/97) <br /> : <br />