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MD <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTHENVIRONMENTAL HEALTH DIV S ONRVIC '" <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 d i[1 �d J <br /> (209)468-3420 <br /> ROR•REFUROABLE UNIT EXPIRES ! YEAR FROM DATE ISSUER <br /> ;Cempla to In TlfpOeElE1 <br /> APPLICATION Ig HIM NY MADE TO THE RAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS At"JeAr1oN 19 WOE IN COMPLIANCE N+rT 11 SAN <br /> JOAOUIN COUNTY DEVE:7-1 <br /> EX�y}�TMA, HAPTER O-11 1�AND III <br /> STA ARDS OF gAN JOAOURN COUNTY PUBLIC JIEALT/1 SIFFMCEA,EnvinONMFNTAt HEALTH DIVISION. <br /> JOB AODFIE99IOn APNI1 JACa� TQC Ct►y /W[/`1 uw/ ' <br /> PARCEL R17flAhFl/ <br /> OWNE.R'B NAME /� . ADDRIEBR /� /� "ROSE f ✓ <br /> CONTRACTOR C�. 11 I'� W _r ADDRFB9 <br /> SUBCONTRACTOR „, F••MM- - <br /> �^, ADLTFIE69 LICI RMIRf f <br /> TYPE OF WELL/PUMP: LIA'�E111/WFlu ❑ REPLACEMENT WFtI ❑ MON'RgRINO WELL/ ❑ OTHER .. <br /> © RJ9TA LATNJN ❑ WELt BYgrEM REPAIR ❑ CROBg CONNECT REPAIR © VAPOR EXTRACTION WELL <br /> J <br /> I � .r'r❑�� 11'P'� OEF"TH PUMP RET FT, <br /> tTVPE OF FUMp1 FIRST NEATER LEVFL O <br /> ❑ OUT or-RR:RvICE WELL ❑ AEommfICAL WELL• © ROft BORITIG <br /> B <br /> DERTTRUCTIONI <br /> lNL—Em DEO Vit TYpEOF CONiTRVGTTGNEpEClFICATIONN <br /> ❑ INOURTrIfAI ❑OPEN BOTTOM <br /> L-�� r-,� MA.OF WEtt EXCAVATION LSA•OF CONOUCTOR CARING <br /> OOIUEBTICIPwVATE HIRAVEt PACXMIZIE- {._` - n <br /> TYPE OF CABRR0I9Tf.EtlpVCle C GIA.OF WELL CAgRFIG <br /> CJ "LICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ry <br /> SF'EClFICATION R <br /> ❑ IRRIOA7gNIAO 11 OTHER GROUT STAL 1"91 Altro BY <br /> ❑ MONPTOISHG GROW BRAND NAME £ <br /> 2 ) OROVF RFAi P[IM1 E6; ❑Vr fl He CGNCiIETE fEDEBTAL BV DRIILETi:L�T�i ❑Ne S <br /> APPRO N-DfpTH !.a+ <br /> LOCKING CHEgTFR NOK/9TOVE PIPE <br /> PROPOSED COr1ETlIl1OT10NIbINWNO METlloq; MILD R4TARV S <br /> AIR ROTAITY AUGER CABLE^OTHER <br />` !NftIEBY CFnTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WrLL BE DUNE IN ACCORDANCE NATN gAN JOAOUtN COUNTY ORN?INANCES,9T ATE tJSWB,ANry MtLEE ANb <br /> REGULATIONS OF THE SAN JOAptRM COUNTY, HOME OWRlER OR LRCENSED AGETI►•g gIgNATURf CfRRNIEg INE FOLLOWMG;'I CERTIFY THAI IN THE PER►ORMAFlCE OF TIIE WORK TOR WlilCll <br /> 7149 PERMIT IR 189M.I SHALL NOT 'CAPONS SUBJECT TO WORKMAN••COMPENSATION tAwo AF CALIFORNIA.* CONTRACTOR'g LAKING OA RUB�OFRT RAC►MG RIONAIVRE CEITR Ir IES <br /> TAE FOLLOWING •1 cERTI T I11 R hF0 ANC F T WORK FOR WHICH►HIB PERIMT M ISEVEO.1 SHAtt fMILtlY PERRONS SUBJECT TO WORNMANy eO11LrRF)fIlA71oN lAWe Of <br /> CAIJFOIVAA.' M T LL 1 1 E Iron ALL REGLSREO INE NO AT 12001 4EEJ42E. COMPLETE '"S w"IO AT LOWER AREA FYIO <br /> j `/� VtDFb. /f <br /> r1T1. <br /> n•I. <br /> KOT PIAN Rh«r I*%.et Sc.R. <br /> T. HAMEN OF BTIIFETN OR ITOADS NEAREST TO OR BOUNDING THE vmptn". <br /> 2. OUTLINE OF TITS PRGPERTY,Gtv*IO DIMENSIONS AND NORTH DIRECTION. - 1_ LOCATbN OF HOUSE BEWAOE INBI'ONAL SYSTEM OR r7SOPOgEb <br /> 2. Dif"MNED OU7UHFe ANO tOCATION OF ALL EXISTING AND g1OPONED 'TXPANEION OF OEWAOE DIRPORAL NYN1EEAg. <br /> @TMPCTUREB,INCLUMNO COVERED AREAS SITCH AN PATIOS,0"VEWAYS,AND WALKS. f, LOCATION OF WELLS vm"w RAOIUN OF ONE HUNDRED rIrry FT. <br /> ON THE PnovERTY OR ADJOIHSIG rnov%RTY. <br /> k kr�r-z � <br /> s 3U: <br /> 71 <br /> Ilk <br /> Iq <br /> . � c <br /> r <br /> ................. <br /> j Y A AAl DEPARTMENT UEE 0141 y <br /> O�•W I.p yrl•n Ar 'r <br /> note �S P+ e In.ewneln�,Ny <br /> O•M <br /> Jn.u�tr.7bn Imp•,Mler.Ry- <br /> � ry•R■ <br /> 20' �'�.n,.�'u . •.� ��,.. tiil , .�._." <br /> AICOVNTINO ONLY: AIDE FAC/ <br /> PE CODES FEE INFO AMOUNT RFMITIfb If K ANTI RECOVE6 BY AAIE <br /> ----------------- <br /> P6tl4BTlsp1VICE pEGUfeT NUMBER INVOICE <br /> . v S� <br /> Plrh Wealth Serv.-EmAro.173(1157) <br />