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r <br /> R <br /> ■ <br /> .r <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH[DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDAREE PERMIT EXPIRES I YEAR FAO ATE ISSUED <br /> Icom <br /> AIYYIC ATION IF MERE BY MADE TO THE BAN JOAOLRN COUNTY FOR A PERMIT TO CONSTpRU1CTIII ANOfi RINSTALL THE WORK OESCEUnD.THIS APPLICATION IE MADE IN COMr'LIANCE WTI,EMT <br /> Jalop <br /> O AOUIN COUNTY OEVELO;-MFNr TrTLf.CNAPrrR 9-I 1 E K-74ANO YHE OTANOAROO�O1F BAN JOAOUIN C/O�UNTY PUBLIC HEALTH SERVICE6,ENMWP4MEMAL IIEALTH DPISMN, <br /> JOB AODRESSA]R APNN �• Ft CJ( 5-.,- <br /> ^�,.. \ I� 4 CI�lTY1y_ L7(. �1 PARCEL 612EIArW1_ <br /> OWNER'I NAME l �i l-L �Z�� V 1. 1 Lt t} �' ar)C.'T,' <br /> ADOFFFOB T�T I p11p11E! ,/��.1 J � <br /> CONTRACTOR u C + <br /> 5NS-COERTUIGYOII r` - UC/ -P..NE A -�1 J.�✓-I[1 <br /> ADOFWSB 1--1 SACT PHONE■ <br /> rYPEOFWEUJPUMP: 0 NEW WELL 4.J mriACEMENT WELL ❑MOHtt OWN01vtm Tv-1 OTIIEA <br /> lJ INSTALLATION ❑WELL SYSTEM REPAIR ❑CROORCONNFCT r%rAIR Q VAMP EXTRACTION WELL, J r <br /> �T\„:!_ 0 New❑n.Pdr II.P. r DEPTH PUMP%,,LZ T. FIRST WATER LEVEL:11 -„ tp <br /> TYPE OF PVMlI t�Y ri <br /> Lr OUr-OF-SERVICE WELL ❑OEOPIIYStCAI,WELL/ ❑ SOIL SONNO <br /> ❑OFSTRUCTtON: <br /> NIFNDED VEE FET--TYIPB OF WELL CON41mm TION SPECIFICATION4. A ~ <br /> F❑r INDUSTRIAL ETJ OPEN BOTTOM CIA.OF WELL EXCAVATION OIA-OF CONDUCTOR CASINO p <br /> 4.1 OOMESTICIRVVATE yIJ nRAVEL PACXIOtrE TYPE OF CA81"MEELMVC DIA.Oy WELL CAMIU1 <br /> ❑viNUCIMUNICIPAL LJ ORIVEN DEPT IE OF OROVI SEAL SPECIFICATION <br /> IRNOATIOWAO ❑OTHER GROUT BEN.INSTALLED BY GROUT BRAND NAME E <br /> ❑MOMrDnNG .-VT SEAL PUMPED:❑Yr ❑H. CONCRFTEPEOEOIALBYORALEn:❑v- ❑N. S <br /> Apmox.DEPTH LOCKIHO CHESTER BUXT■TOVE PIPE <br /> PROPOtFO CON4TnVCTION1ORILUNG METHOD:MUO ROTARY AIR ROTARY AUGER CABLE. OTHER <br /> ME BY CERTIFY TI/AT I HAVE PREPARED THIO APPLICATION AND THAT THE WOM AVRL RE CONE N ACCORDANCE WITH SAN JOAOLIIN COUNTY ORDINANCES,STATF LIAWR,A"RULE <br /> nEOLAATIONS OF THE BAN JCAOUN COUNrY.HOME,OVMIER OR'MtMaFD ADENT'■SIGNATURE CEATN IEE THE FOLLOWU40:-I CERTIFY THAT N TNM PERFORMANCE OF THE WOM FOR VA <br /> TIME PEWIT IB ISSUED,I SHALL NOT EMPLOY PERSONS■UBJECT TO WORRMAN'■COMPENSATION LAWS OF CALFORWA.-CONTRACTOR'S WRING OA SUB-CONTIL CTINO LMNATVRE CERTRIE <br /> THE FOLLOWNO: '1 "11"Y THAT INTIM PERFORMANCE OF TIRE VVoM Me WHICH TMS PERMIT It ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORRnURP-9 COMIENSATMr1 LALW O <br /> CALIFORNIA.'TFM 'V T VST CALL 2A IOIIRM IN ADVANCE FOR ALL NEIWIREO INIPFr-' D(k�AT tiMl Aa.22.COM E DRAWING AT LOWEn AREA PF1OVW0. <br /> mc-I •J J <br /> T M D.. <br /> ROT PLAN FIN ro I.W <br /> 1,NA MEI OF STREETS O ROADS NFAREBT TO OR BOUNDING TIN PFIDF`E Y. 4.LOCATION OF I/OVBE MFWAOF DISPOSAL SYSTEM On PnornSEO <br /> I.OWL"OF T"I!PRO TV Y,DRANO DIMENOfONI AND NORTH DIRECTION. EXPANSION OF■SWAGE OIOPOSAL■YITEMM, <br /> O.DIMENSIONED OUTU S AND LOCATION OF ALL EAISIINO AND PIIOPOSEO a.LOCATION OF WELLS WrpUN RAOIIA OE ONE MINOEFU FIFTY FT. <br /> Gf RUCTVR[B,NCLUOINO COVERED AREAS SUCH AE PATIOI,DR10EWAY9,AND WALK$. ON THE PROPERTY OR ADJOINING PR OVE$". y <br /> til <br /> lee <br /> PAYMENT � <br /> JUN 23 1997 <br /> 1�{ snrrariaaut torr^C <br /> PUSUO HLTM SE7iVICES <br /> FA <br /> ENVIRONIVIEKTAL HLALTH r1rVISI.'fr+� <br /> D ARTMLHT USE ONLY Y' <br /> APPIkwrI A.-UPI BT `e ms ON. Z Arum <br /> GIM 1--w.BT ON. r-P 1-p-a-Ry j� D..�y <br /> J <br /> OrelrAellen rrVR.ed.n Iy p„� <br /> Cnmmr.e' <br /> ACCOVxrWO ONLY: Ax/A <br /> FAUN <br /> FE CODES FEEFNFO MOUNT REMTITO /-­o-;L CRECEIVED RY DATE PEYMMTr■FINALE REG ST MUMMER INVOtct <br /> 6 D / <br /> Pub.Health SerV.-EnV[rO.173(1/97) <br />