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APPLICATION FOR WELL./PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESFILE. <br /> COPY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NON-REEUNDIIBEE PERMIT EPIRP$1 YEAR FROM PATE ISSUED <br /> icaMpkis in TripRRBt.I - <br /> APPLICATION IS HERE MY MADE TO THE SAN JOAOUN COUNTY FOR A FERMET TO COMSTR/CT ANCIMA INSTALL THE WOW Of M"REO.TIPS APPLICATION IS MADE IN COMPUAMCE WT111 SAN <br /> JOAOURI COUNTY DEVELOPMENT TITLE,CHAPTER$-1115.7 AND THE STANDARD*Of RAN JOAOUIN COUNTY PIMUO HEALTH SERVICES.FMIRONMENTAL HEALTH OMSIOM. <br /> JOB ADOPBSRAR APSE �L J'( W ` T---f- CITY PAE1C SIZF/APHI <br /> OWNER'S NAME JT�TOYj'�T I lm+ 1 1 ADORERS_ P'^tr'-pp7 <br /> / _J_ PIxREI <br /> CONTRLACTOII_�(ItiR_�P/— Vii-( ADORERS FOGS KIlw,.7 9c nrr,R UcE_a4 24.2/!r-PIIOHE0 467-29,)2. <br /> MIS CONTRACTOR ADORER UC. HpM P <br /> TYPE OF WfLUPUMP; )(�'E1( NEW Wf11 E�gACEMEM WELL ClMONA ONNO WELL E ❑OTHER <br /> —Q mmi8L mw ❑W"L►BYoTEM 1�►AIR- .� 0 CROs"ONN[CT RVAIR Q VAPOR EATRACTIO_N WELL E J <br /> 13 N—❑MPi N.P. DEPTH PUMP SA—R. FIRST WATT"LEVEL O <br /> IT—OF PVMPI <br /> f^ �� ❑OUTOFSERNC/E SWILL ❑ <br /> �DtRimxiroN- (�J..G(�lY 1T"ri. G- f (�JL���OEO � UL ❑ POIL BORM S <br /> M EN i CONSTRUCTION SPICRIC TIONS t! P� A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM OtA.OF WELL EXCAVATION n L! DIA.OF CONDUCTOR CARING <br /> I � CARI.NG , O <br /> %-DOMESTIGORVATE $OMVEL►ACXISIIE� TYPE OF CAS*?M.Tfft AOF WELL CARING & O <br /> 11 RSt1CMUHICPAL 13 DM%MN OEIRH OF amour REAL BCR CATION 1&o +n } R <br /> ❑IMATIOWAO ❑OTHER OROUTSRANDNAME C-ekU <br /> r�I/ E <br /> ❑M O1RMG ORO VT REAL PUMPED:❑Vw [IN. COMCAETE PEDESTAL BY DRufFt❑Y- IYN. s <br /> APFROX.DEPTH LOCKING CHESTER BOXATTOVE PIPE s <br /> PROPOSED CONSTRUCTIONMPFLUIEO METHOD: MUD ROTARY AM ROTARY AUGER CABLE OTHER <br /> I HMIFY CERTIFY THAT I MAVE PREPARED THIS AFAJCATION AND THAT THE WOFW WILL of DONE IN ACCORDANCE WITH BAN JOAOLIIN COUNTY ORORIANCEP.RATE LAWS,AND IWLA.ANO <br /> MOULATIONS OF TNS RAN JOAOUIN COlUHEY.HOME O%MMfA OR UCENGED AOENT'f WONATURE CERTRES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH <br /> THIS PERMIT S ISPUEO,I SHALL NOT fM�DY KRSOMS SUBJECT TO WORKMAN'S COMPINSAMN LAWS Of CALMOINIA.-CONTRACTOR'S HIFRq OR PUS-CONT ACTNO SIGNATURE CERTIFIES <br /> THE FOLLOWNGt '1 CERTIFY THAT M"Of KAPORMANCE Of TER WOW FOR WHICH THIS PERLOT It 16WIT).I SHALL EMPLOY PERSONS SUBJECT TO WORTOAAN'S COMPSKSATWR LAMES OF <br /> CAUfO1RN1A.' TE DANT MUST !•HDVRS IN AAMC.POR ALL RSOUH1m NRPscrFglj.AT ITWI.M—n.col— TE ORAM4No AT LOWER AREA PW VIDEO. <br /> MSrw.x �/L'L.: TRI. ,/Ji,.`-t�l�]Q D.. /G-9 :w <br /> OT PLAN Din.1.U0.1 U. <br /> 1.NAMES OP STAEETe OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. .. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PAOMREO <br /> !.OUTLINE Of THE PIIORRTY.ORIRIO MMEHNONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> ],DIMENBIOREO OUTLINES AND LOCATION OF ALL EXISTING AND PIKLPOSED S.LOCATION OF WELLS W FFHFH RAMS OF ONE IKRtOMD FIFTY FT. <br /> STRUCTURES,NCLUDNO COVERED NEAR SIKH AS PATIOS,DRIVEWAYS,AND WALICS. ON THE PROPERTY OR ADJOININO PROPERTY. <br /> ....... ... :.. :. ... ... .. <br /> LLJ <br /> ...... <br /> OST 2 31998 <br /> Ac.T�iA <br /> AIV JOAUUIN cY3UPErr, . <br /> PUBUCK ,TH'SERVp E6 ` <br /> ��AA11 .... . <br /> EMlIFQNMENIALklEALTH WVi$ `" ! <br /> A �s <br /> w <br /> MTMDIT VK GRLY DN. /O A,--IL A.PBwII—A...PIM By <br /> O«. -J- .eII.,,er D«. <br /> � <br /> �g:ea a� .w ers,tiry-2.0 ' wDLAT Aa' o cc.A �" � o+sem <br /> UO EC ZY <br /> 'I'off XP.Vfve, :,asAt w PAR,VA.QG-"r/o •7.2j4A0 l9,/llRlRw— , <br /> ACCOURTrNG ONLY: NDE <br /> M COVES FEE INFO AMOUNT REAOTTEO CHICK"NICASH RECEIVED By DATE FgRM TTSFAVRC[R[OUSAT NUMBER INVOICE <br /> 1p a p D/ <br />