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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 ( j <br /> (209)468-3420 <br /> DOId•REFUNDARIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplata In T71pDpatal <br /> AFPUCATION I911FRE BY MAM TO THE BAN JOAGUINCGVNTY FOR A PEN/IIT TO CONSTRUCT ANVIOR INSTALL THE WORK MSCRIREO.11118 APPLICATION IS MADE M COMPLIANCE WRIT SAN <br /> JaA0U1N COUNTY DEVELO/p/ME TRLE. N+AP7TFR 8-111AND <br /> /JTHE BTA ARAPB OF SAN JOA9111N COUNTY <br /> ''/R�J1R/U/JC�}�EALTH 6ERNCE6,ENVIimNl.7ENTAL HEALTH OM><ION, <br /> JOB ADD RED&OR APNI / ` /',�w//���4•//�A`--I/^-� �" -�F{, _C `' --.' PARCEL SIIEIAPNJ <br /> a"^^ � �{ <br /> OWNER'S NAME�qq��y�. CL.. _- AOOAE89 nnK /�f PHONE! <br /> LOMRACTOR L.- �� <br /> ADDRESS(�JL7r�. •y�E1C/ F'HONER 5�/2-1G <br /> jSUBCONTRACTOR ADORED" tICO PHONE <br /> 1 E-� <br /> TYPE OF WELLRMP: UOl<W WELL ❑PMRACEM NT WFLR ❑MONTORINO M4ELL/ ❑OTHER <br /> .❑y M/67A�LATNJN ©WELL 9"TEM REPAIR <br /> CFS088CONNECT 71EPA1R ❑VAPOR EXTRACTION WELL/ <br /> , � i-.YNsv L.i liq!•M H.P.I_ OEpFN PUMP BET ET. FIRRT WATER LEVEL O <br /> [TYPE OF PUMPI <br /> ��', ❑OUT-0E-9ERViCE WELL ❑OEOPITY61c AL WEfJ_! ❑ SOIL BOwNd B <br /> ❑OESFRUCTION <br /> iI INTENDED USE TYPE OF EL.L CONSTRYCTION 1PECIFICAt1oNa p / A <br /> ❑,INOOuSTRIAL ❑.OPEN BOTTOM VIA,OF WELL EXCAVATPON 4 VIA.OF CONOUCTORCASMO U <br /> L•<NIEBTICIPRIVATE Ef`G AVEL PACKMIZ£�_ TYPE OF CASfN615TEELIPVc,�, , dA.OF WELL CASINO O <br /> ❑PU8LIC/MUNI;FAL DRIVEN DEPTH OF GROUT SEAL 6PFCFICATION R <br /> a ❑SmMAIRONJAG ❑OTHER GROUT SEAL INSTALLEDBY IICtAo0cyy GROUT BRAND NAME FF�� E <br /> n ❑wowt OA1Na GROUT DEM RN.IPEO:❑Yr Ll AM CONCRETE MMAYAL BY DRILLER:L•TT�r ❑N. S <br /> APPROX,OSPTN LOCKING CHESTER BOXWFOVE"PE S <br /> I 3 PRoPOaaD CON{TRUCTIomnmw VFo METMobl NWD ROTARY L"/AIR ROTARY AUGER CABLE OTIITR <br /> 1 Nt4EBY CERTIFY TI4AT 1 HAVE PREPARED TNR APLICATtON AND 714AT THE WORK WILL BE DONE M ACCORDANCE WfTH BAN JOAOUIN COUNTY ORDINANCES,"TATE LAWS.AND RULED AND <br /> ROUlAT10N8 OF THE DAN JOAOUIN COUNTY.NOME OWNER OR LICENSED..—'I SIGNATURE CERTFIEa THE FOLLOWING:-1--T HAT IN THE PEWORIuIANCE of THE WORK FOR WNCN <br /> THIS PEINLR IOMMO.1"HALL not RBONS BUMJECT 7O WOMMAN'{COMPENSATION LAWS OF CALIFOTI{A.'CONTRACTOR'S WRr No OR SUS{ONTRACTMO BIONATURF CERTIIE2 <br /> THE FOLLOWING '1 CEIRI �"". <br /> R ANL F T R F7,"19 IMBUEDI SHALL EMPLOY FERBONS SUBJECT TOWORKMAN'{COMPvnUttIVN LAWS OF <br /> CALFORNIA.' LL 1 1 AN S FOR ALL REOUREa MMP ONi AT fta/8I14/�tlt•.f1/511.C�OM/PLETE DRAWING AT LOWER AREA PTKINOEU. ,E.� <br /> X <br /> ROT PLAN 03 <br /> T.NAMES OF 11TRESTS OR ROADS REMEDY 10 OR MUNOINO TIE PROPERTY. 4.LOCATION OF NOUBE SEWAGE OIBPODAL OMF1.1 OR i'Fg1OSED <br /> I.OLMW OF THE PROPERTY,OIVBIO WMENDIONS AND NORTH DIRECTION. EXPAWON OF BEWAGE DISPOSAL BYSTEMS, <br /> 3.VDUrNSTDNEO OUTLINES AND LOCATION OF ALL EXIDTNJG AM PROPOSER {.LOCATION OF WELLS WITHIN MONS OF ONE HUTIbREb FIFTY FT. <br /> STRUCTVFDES,INCLUbMO COVERED AREAS"UCH AS PATIOS,PW VEWAY8.AND WAILS, ON THE PRVPFBT1'OR ADJOMM PROPERTY. <br /> �: s ii tJI <br /> R <br /> 6{ <br /> 14 <br /> i <br /> w <br /> Q <br /> , I <br /> NIS! . . <br /> 1 / DEPARTMENT USE ONLY <br /> ApPS..0—AppePf.d B!' �/(�j�'`/UL//i/ // <br /> a—In.P.H—By "�'r T/bR. o.a �•� C Pu,ro Im_d_BF D. <br /> D., <br /> Onlnalk.,Irrn..l1 aF <br /> din CAd, <br /> t�A a-ce <br /> a az �L �- <br /> ACCOUNTING ONM ATOP FACE <br /> PE COVER FEE INFO AAOUNT REMITTED ,El ASI RTCDVLD BY DATE P131MIT1/EAVICE RFOVEaT NUMBER INVOICE <br /> 'q3: 3 `� x3� ; po<9Li0. <br /> 3 l5v Y. �� S� S VY <br /> �cl+ssuL 116 3 <br /> 1 <br />