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0 <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (208)468-3420 <br /> RDR•REFDRDA9EE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> rk"IEtB In TrIpRe■r■I <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR BISTALL THE WORK DESCAIBEO.THIS APPLICATION 18 MADE IN COMPLIANCE WRH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE <br /> STANQAR OS O�#f NN JOAQUIN COUNTY PUS HEALTH SERVICES,ENVIRONMENTAL HEALTH OVARION. <br /> JOS ADoacs3,OR APHF L6 I r_�r .�kc oL C3 m f'1��_/kql —crry h1J ! PARCEL StZEJAPNO f / <br /> OWMR'e NAME // nL,1 / V Appl¢BB Sr, <br /> COHTRACTOR�EF a/, 'y NA7 L — ADORES.a0 T E,.04,10 -S <br /> SUBCONTRACTOR r�T ADDRESS �'J LIC PHONE! <br /> TYCFP WELTlP11MP' ❑NEW WELL ❑IFIiACEMEHT WEtE ❑MONRORIHO WELL f ❑QTHER� <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CRDSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL F J <br /> ❑N—❑Rep* H.P. DEPTH PUMP BET_FT. fIRST WATER LEVEL p <br /> RYPE Or PVMPI �ryry <br /> ❑OVT-OF-SERVICE WELL y GEOPHYSICAL WELL E ❑ SOIL 9OMNO B <br /> ❑OESTRUCTIONr <br /> INTENDED VSE TYPE OF WELL CONSTRUCTION SPECIFICATION. NQ�� A <br /> 11rI1VITSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION INA.OF CONDVCTORCAONO p <br /> ❑DOMESTtrMWVATE 11 GRAVEL PACKIMZE TYPE OF CAMNOIS rfFLPVC VIA.OF WELL CA61NO p <br /> Qry PVRULI <br /> CIMNICIPAL QVMVEN DEPTH OF GROUT SEAL SPECIFICATION R_ <br /> 13 MMATIOINAO ❑OTHER ORDTrT SEAL INSTALLED 5Y GROUT BRAID NAME I•--I <br /> ❑MONHOPoND � OROVT SEAL PUMPED:❑Yr ❑N. CONCRETE PEDESTAL BYDRILL.ER:❑V- ❑11. S Q <br /> APPROX.or." .T LOCKING CHESTER @OXISTOVE RIPE $ <br /> PROPOSED CONSTRWlnONAXIRAND METHOD: MUD ROTARY AIR ROTARY AUGER C. OTHER <br /> I HERESY CERTIFY THAT 1 HAVE PREPARED THIS ATYIrCATION AHO THAT THE WORK MILL SE GONE M ACCORDANCE WNH SAN m^cmtN COUNTY OROINANCEB,STATE LAWS,AND RULER AND <br /> REGULATIONS OF THE SAM COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WIRCH <br /> TMS PERMR IH BITE 1 NO OY R SMBJECT TO WORKMAN'■COMPENSATION LAWS OF CAUFOWIA.'CONTRACTOR'S HIRING OR SUB-COHTRACIWO SWNATVRE CERTITrE. C <br /> THE FOLL C THE ANCE OF THE WOW FOR WHICH THIN PERMIT IS ISBUED.I SHALLL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPETISATION LAWS OF �+ <br /> CALIFORNI M ■ CA NO <br /> IN ADVANCE FOR ALL IIEONRED MS N■AT Elm]Ip OMRET{ HG AT LOWER AREA PIgV1OED. r/ <br /> •//� /ry) f/� ) 1� S <br /> GIG."X TION, C� L'- \ _L- __ Die. O ` <br /> PLOT PLAN CO—ro Sa.N.I <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDMD THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSEO <br /> 2.OUTLINE OF THE PRDP"wy.OTVIIRr OTMENSOONII S AND NORTH DSECTXM. EXPANSIUOF SEWAGE DISPOSAL SYSTEMS. L' <br /> 3.OGMTNSIONEO OUTLrNF.0 AND LOCATION OF ALL EXIBTWO AND PROPOSED S.LOCATION OF WELL@ W TNIH RADIUS OF ONE HVRDIED FIFTY FT, ` <br /> STRUCTURES,DICLVOINO COVERED AREAS.MCH AS PATIOS,DPIVEWAYB.AND WALKS. ON THE PROPERTY OR ADJOINMO NOPERry. <br /> e <br /> '....' <.... --SSSS.:... .. .-.._ <br /> ' <br /> - _ <br /> , IZ <br /> .Yo <br /> j <br /> l OCT. 26 3998 <br /> <a1'f C J' 'III t I5 <br /> _- <br /> N <br /> f ONLY / <br /> A"6.HI.n A—td d BY Pzzz— <br /> I. a Air `^ / <br /> If <br /> G'..ImPenlen By On. I/n.r'I..By OH <br /> Drwl,A'elbn MwPaetbn Sy Ia <br /> COm N: �L <br /> ACC ....OMT: Alb/ FAC/ <br /> TR Caere fEEMFoq AMOUNT 11TAGIlEb HEC MANN REEEfVEO IV DATE PERMITI■ERVICE REOUE■T FIUM/81 INYOICE <br /> 'jC b i � �. <br /> Fk !' <br /> 1 <br /> 0..4 4..nNM Senr Fn,rirn 171!11071 <br />