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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBUC HEALTH SERVICES COPY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)488-3420 <br /> RUN-REFUNDABLE PERMIT EXPIRES 1 TEAR FROM DATE ISSUED <br /> (Camplets III RI <br /> APPLICATION le Iff RE BY MADE TO 711E GAN MAOUN COUNTY FOR A PERMIT TO CONWRUCT ANDARINITTALL THE WORK Df BCRNED.TIME APPLICATION N MADE IN COMPLIANCE WRIT GAN <br /> IOAOUIN COUNTY DEVELOPMENT TRLI,cHA►TER 9-11115.3 AND THHEf 67ANGA $OF SAN JOAMN COUNTY MOM HEALTH EERVICEE.11VMGNMENTAL HEALTH OMEgN. <br /> JOS ADDREELOR APN/ I(-- Y ( CITY PARC L azF/APNI <br /> OWNAR'E NAME / ilm��IY1a AOOIIEss_ 01 a <br /> COMMCTOR �.L!�! TF" lJ I-[ //Yt c7 AOd1EEE.FOOT Ilei-n.i 9CtF) LIC/ 4?r•/'1/k.PF/ONE/ �In7�.1'� <br /> C 7 <br /> AM CONTRACTOR ADDING" L1GI PHONE/ <br /> TYPE OF WELIRLR/PI xIGW WELL �,REPLACEMENT WELL ❑MOOTONNG WELL/ ❑LLOTR <br /> ❑INSTAATION _ ❑ LL WESYSTEM IG_►_NR ❑CM8"OWACT REFAP_ C] HI yAHI EXTRACTION WELL/ J <br /> ❑N.-❑RR.PI. N.P. v DEPTH RUMP BET_TT. _ _T FIIU'T WATER LEVEL _ O _ <br /> (TYPE OF PUMPI <br /> ❑OUT-OF-RFRVIC/EE W <br /> ELL ❑otomy I/C/A/L WELL/ ❑ SOIL BOLERO E <br /> $OERRHUCTION: /�I- l✓1>`"FL (i/1�d.f` l /'l ..n /I/71�F/��"T / <br /> NEI TfNOSO w[ TTPE op wEIL d�CON-E TTRUC A IONS 11 q <br /> Cl IND UGTNA ❑OPEN BOTTOM DIA.OF WELL EXCAVATION OTA.OF CONOUCTOII CANING O <br /> %,D0MEE7ICIPRIVATE $AMVEL IAC./SUETYPE OF CAENO/S7EFLA-M .0 <br /> �RV�, G- CIA.OF WELL CAGING &��TIl O <br /> 11UMJC/M <br /> PUIRcm L ❑DRIVEN DEPTH OF GROUT SEAL /NP/Y " EPECKICATK)N J(fy Ygg T_ A <br /> ❑M"ATION/AO ❑OTHER GROUT SFAL INSTALLED SY /J/-C /.p f-_ OFIOUT BRAND NAME L 174 CJ F� F <br /> MT <br /> ❑MOONNI GROUT NEAL PUMPED:❑Yr ❑UM CONCRETE PEDESTAL BY DAKLER❑Yw lliw. s <br /> APPRG I.D " to"'NO CHESTER SO%ATOVE P q <br /> y S <br /> MOMSED CON DRUCMNAMLLIIO METHOD:MUO ROTARY ADR ROTARY AUGER CABLE OTHER <br /> 1 HERE*Y CERTIFY THAT I HAVE PREPARED THAI APFLICATON AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH GAN JOADUN COWRY OF/RNANCt*,STATE LAWS.AND RULES ANO <br /> RFOULAT"M OF THE GAN JOAOIAN COUNTY,HOAR OWNER OR L10ENWD AGENT'*SIGNATURE CERTSIEB THE FOLLOWING:'1 CERTIFY THAT N THE PERFORMANCE OF TllfGWORK FOR WHICH <br /> TNN PERMIT IS NSUEO.1 MRALL NOT FMkOY PMOONS SUBJECT TO WORKMAN'S COMPAIBATION LAWS OF CALFORIIA-COMRUCTOR'*MPWM OR"-COMRACTNG SNATUIE CtRfEG* <br /> TNT FDLLOWNO: •1 CtI flFY THAT N TIE PERFORMANCE OF THE WORK FOR WHICH TME PERMR 1*ISGUEO,1 SHALL EMPLOY PERSON*BLISJECT TO WGPDOHAN'I COMPENSATION LAWS OF <br /> CALGOWAA.• 71 CANT Mwi A N NOW IN AOVANCB FOR ALL REGUMLSB IMSPIC/ �ATS flW�E7 4"p 23.COMPLETE 0 VYING AT LOWER AREA PILO/VIDEO. <br /> TIO. 9- <br /> OT PL.AR F....ti*..I.I Be.1. Ie <br /> 1.NAMTS OF*TRENT*OR ROAD$NEAREST TO OR BOINDI G THE PROPERTY. t. LOCATION OF HOwt BFWAGE DIGFGSAL GYSTFM OR RgPOGED <br /> }.oUTLNE of THE PROPERTY.GMM DMENIIONI AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BY$TtM*. <br /> JIAF <br /> .OINGIDRGD OUTL1Nt8 AND LOCATION OF ALL EXISTING AND F/OPOWD S.LOCATION OF WALLS WTTMN MONS Of ONE HUHOIED FLTV R. <br /> GTAUCTLIIES,NCLVMM COVERED AREAE SUCH AE PATIOI,DIVEWAYI,AND WALKS. ON THE PRROPERTI'OR AD"wame PROPERTY. <br /> .. .. <br /> PAYMENT � <br /> ar^"`4PF� 1/ <br /> OCT 2 3 1998 M+Ii <br /> SAN JOhUU1fV L:buKh <br /> of .. <br /> PIfHJCHEhLT l ERVICES <br /> QIVIRONMENYALMEALT.H UlVISi <br /> Q _ .. .. Lqell �WILII <br /> ARTMEN7 w[ONLY Q / <br /> a...I...P«II..,er DI.e. -.T• R..,P n«.er Ow. <br /> D..I...IH..I....s D.I. <br /> .�:��$ Y I r C SANb -ID � m"'Ir �i VD CLEF � iSO+Se*4 <br /> a VOI fC ✓t -2Y Afi,{u AWYvN T�8 wsAc sv tiFQt.. <br /> AccouNmro oNLT: AA/ 9TH l� fA'Oo.VUuO�Y �NzoN/Z�FNNEse•.rF: <br /> PA CODE$ FEE INFO AMOUNT RRYIITTTTI CIGCIUF:A*N RECOVEO BY DATE ►BWII TISTRVKE RSGRR*T NUAGAR INVOICE <br /> p o — d/ z <br /> o D'YJ� ✓ ' Z <br /> Pub Health Serv.-EnVINO.173(1/97) <br />