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I <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JOAOUIN ST,STOCKTON.CA 962013/1 <br /> (209)499-3420 <br /> IIOWR6UNDABLE PEDMIT EXPIRE3 1 YEA FROM 097 13[_ EU[D <br /> rf pbh i/Tfwimt.I <br /> APRILATON IS HERE UY MADE TO THE SNI JOACUIN COUNTY FOR A PERMIT TO CONtTRUCT AND/OR INSTALL THE WOOS(DESCJ%wD.TM APPLICATION 19 MME N COMPUA!PCE WITH SAN <br /> JOAOUIN ODINRY C"LOPLLENT TITLE,CHAPTNI 9-1115.3//AND THE VTANb OF CAN JOAOMN COUNTY PUB C HEALTH SERVICFI,ENVMIONLIENTAL HEALTH DINMON, <br /> JOB NODRE[6AR APH P/L CITY PARCFl S=AFIIS_ <br /> OWIRII'S NM4 AD011EW PHONE/ <br /> CONTRACTOR S[ Lbcf__ M</-/.F�-:m<Z-/"N <br /> SUS COWKACTM �F AOORFA! UCJ PHONE/ <br /> TYPE 0/WTLLiftMt 1iE NEW— ❑PwiAcEwmT WELL ❑MONITOMIO WELL/ ❑OTHlf1 <br /> ��f ❑ Cl W <br /> /OVALLATION WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAKIP1 EXTRACTWA WIEL S J <br /> fua-, DEPTH PUSl wr 9-f. FIRST WATER LEW O <br /> (TYPE OF PUMP <br /> ❑OIITOF-SERVICE WELL ❑GEOPHYSICAL WELL/ ❑ SOIL O fmw, S <br /> ❑DLTTRIKTION. <br /> woracp USEN nem/ CATICI M // / A <br /> ❑1 AL OPEN BOTTOM FIA.OF WELL EXCAVATION DIA OFCONDUCTORCASMO O l <br /> NEST MIPISVATT ❑GRAVEL PACVJSQF TYPE OF CADINGISTELLNVC DIA OF WELL CASNO D <br /> ❑PRJSUClMUNICFAL ❑DImVEN DEPTH OF GROUT SEAL 162,0SASEICATIOM R <br /> ❑SWOATIOWAO ❑OTHER GROUT SEAL NSTALED OY rT ORDUT SRMO NAME E <br /> 13 IAONiToISNG GROUT SEAL PIR.FEn:ClYr El <br /> CONCRETE PEDESTAL SY ONUFR W. ❑Ne 3 <br /> APPROX.SF1TN If / _ IDCJ(WO CIEBTEA t01[ffTOVE FpET__ , <br /> PIIOPOSm CONSiRYCT10IA1SWRO SISTIIOD:WbROTA" NR IbNI <br /> TARY GER _CAME ✓ OTNEEI , ^ <br /> I HERESY CERTIFY THAT I HAVE PT�AWD THPP <br /> IS APPLICATION AND THAT THE WOFSC WILL SE DONE IN MCOFDANCE PATH SAM JOAOUIN COUNTY ORDINANCES,STATE LAWS,AMC RULES AAD V ' <br /> REGUTATONS Of TIE SAM JDAOUPI COUNTY.NOME OWNER OA LICENSED AGENT'S--TUPL CERT*46 THE MLLOV.MG:'I CEKTEY THAT IN THE PEFW40M AWE OF TIE 1AOW FOR WHIOI <br /> THIS POMR It WKEO,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WO M't COMPENSATION LAWS Of CALIMW..A'CONTRACTOR'S 1,11—OR SULCONT'RACTWG SMINATlim CERTIFIES <br /> TIE FOLLOWING: '1"FITIFYTHAT IN THE RF01M1ANCE OF THE WOFK FOR YWKH THIS POINIFT IS ISSUED,I SHALL EMPLOY PERSONS GUILJECT TO WO.MY COMPVPSILTION(-AWS OF <br /> CALVOPPAA.' OHS CANT MU i C 1 IN NNAMCE 1'911 ALL REGISIIm INSP OMt AT 1-1 ASS JM7S.COYPU:TE DRAWING AT IDWER NEA FNIO VDED. <br /> 14 <br /> li PtPLAR ce SaJq <br /> OUSE <br /> 1.NAMES Of STREETS OR MDMNEAR <br /> EM NEA M TO OR SOUNIN2 TNF ;711 A.LOCATION OF HSEWAGE DISPOSAL.SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY.GIVING DK*PAWNS MIO <br /> D NORTH D IDN. EXPANSION OF SEWAGE OMM <br /> POL SYSTEMS <br /> S.OSIONSIONED OUTLINES AND LOCATION OF ALL FXLSTWO AND PIIOPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDAM PIETY FT. <br /> STNICTURM INCLUDINO COVERED MEAS SUCH M PATIOS,OP VV AYS.ANU.NAI. ON THE FIDPERIY OR A0JOIE M PIIOP[RTY. <br /> Q : ........ <br /> ........... <br /> .. PAYMENT.... <br /> -RECEIVE : <br /> :JUN: 5 1995. ..... ... ..........: <br /> SAN JOAQUIN C0014TY <br /> PUBLIC 4ALTH,'5ERVI S ; <br /> ENVIEONMENTAL <br /> pOAREAIETIT LOSE ONLY <br /> APg14wA.n A1or M OrP <br /> G.aA.mP.rPanSYT <br /> O-k <br /> ACCOUNTWJ GNLN. NO/ FACF ��DOt71p � �J <br /> Ft COO" FSE IIEO AMOUNT RpETTEb HSC AMA RBBVLD SY OATS POPPATNMIVICF R49LMAT RILalMl INVt.LCS <br /> tf3 O/q o6 <br /> '3 019 063 <br /> SQc O Solo <br />