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f � <br /> APPLICATION FOR WEIL{PUMP'PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.80X 388,304 EAST WEBER AVENUE,STOCKTON,CA 96201,M <br /> r_ <br /> 12081488.3420 \I} - - <br /> NON-REFUNDABLE PERMIT XPIAES I YEAR ROM DA E I'SUEO <br /> AFFTICIC&mp6t/In TripBF/E&I - y <br /> JOAQUI CO N HERE EL MADE TO THE SAN JOACHAPTER <br /> 9IIF COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR IITSTALLl1HE VJonK DESCRBED.TfGB APPLICATION IB MADE IN COMPLIANCE WffN BAN <br /> JOAOULH COUNTY DEVELOPMENT TRIP,CHAPTER R-111 5.3 AND THE STANDARDS OF BAH JOAOLKH COuNry PUBLIC HEALTH StAWCE T ENVIRONMENTAL HEALTH DIVISION. <br /> j JOS ADDRE9&OR APN/ II <br /> CITY. StOCkto'n'� <br /> I OYHEER'e NAME Co PARCEL eIZE7APN/ <br /> ADDRESS 6100E. .Shiela St. LA 2�3_72�X08 <br /> CONTRACTOR h lento & ASSOC. RHONE <br /> { AODWSS PO Bx 547 ':Menlo LIC, 592722 A <br /> BUB CONTRACTOR ��,PHONE Ad�S D C n n.Z <br /> ADOPuw TPark ��4 <br /> RH > PHONE <br /> 1XfLo MP' ❑NEW WELL ❑REPLACEMENT WELL _ <br /> ❑MONRORNO VYELLI I - ❑OTHER_ <br /> ± <br /> E3 INSTALLATION ❑WELL SYSTEM REPAIR ❑CIb88CONNECT REPAIR y ❑ ��•` <br /> "^ (3 N—11R.p+x H.P. d VAPOR EXTRACTION WELL/ J <br /> HYPE OF PUMP DEPTH PUMP SEI F7, I' <br /> FIRST WATER LFVEI��_ � <br /> j ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL IT ' <br /> WOESTRUCTION; .1 ❑ SOIL SWUNG ; 8 <br /> KJ PE O W OC N/7N11CTIDM/PECIFiCATIDMIt ' <br /> ❑INDUSTRIAL E3 OPEN SOTTOM A <br /> - ,. r-a�.�J=L.L °LIT$ <br /> ❑DOMES7ICmVATE ❑GRAVEL PACK/aIZE OTA.OF vhLL EXCAVATroN <br /> A.OF CONOUC70R CASINO O <br /> ❑PUBUCAMUNICIPAL ❑DRIVEN TYPE OFCASDHO/BTEEUPVC <br /> IMA.OF WELL CA&NO D <br /> DEPTH OF SRISEAL - SPECIFICATION <br /> ❑MONITORING ❑DTNE0. GROUT SEAL INSTALLED BY -i, & <br /> MONITORING - - ONOUT BRAND NAME E <br /> GROUT SEAT PUMPED:❑Y.r ❑Mo r i� SY ORLLER Ely- [IN. S <br /> 1 APPROX.DEPTH CONCRETE PEDESTAL <br /> LOCKING CHESTER BOXISTOVE-RPE <br /> PROPOS®COil&TRUCTIONMNLUNO MEFHOD: MUD ROTARY <br /> - AIA ROTARY AWER CABLE <br /> a7HEik ' <br /> I HERERri tERTOY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE GONE IN ACCORDANCE WITH SAN UOAQUDI COUNTY pRO1NAEHCEB,STATE IAWB,ANp!!!TEES AHD <br /> REGULATIIONS OF THE SAH JOADUIN COUNTY. HOME OWNER OR LICENSED ApEM'B BILL BE DO CERTIFIES THE FOLLOWING:Y t PTIFYAOU0 THAT IN THE IH <br /> TNI&PERMIT IB ISSUED,I MALL NOT EMPLOY PERSON$SUBJECT TO WOR KMAN.&C OMPENSATION LAWS OF CAUPORNIA.•CONTRACTOR'S HIRING OR SUB-CONTR�i1yT8fO SIGN YURECERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORE POR WHICH THIS PERMIT IS I&&UED.I SHALL EMPLOY�,PELIeOHE BULUECT TO WORKMAN'/ TNG Sd/ATLDM IAMB DF <br /> CALWOIINII THE APPLICANT MUST CALL 24 HOURS IN AOVANCS MR ALL KEQLMEO INSPECTIONS AT 1!O&14q.-14=a.COMPETE DRAWING AT TOWER AREA N'SpfbtGUD. <br /> SIDI M )k <br /> 711N <br /> Ott. <br /> TROT PLAN jor u&oM61&q.I• 'Ir iii .•�� <br /> 1, NAMES OF STREETS OR RGAOS NEAREST TO OR SOUNDING THE PROPERTY, <br /> 2,OUTLINE OF THE PROPERTY,GIVING OIMENBIONB AND NOFTTIL DIRECTION. �• LOCAri)N OF HOUBE SEWAGE OHSPO&AL SYSTEM OR PROPOSED <br /> 1,DIMENSIONED OUTLINES AND LOCATION ALL EXINO AND PROPOSED a EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> RI <br /> STCTURED,INCLUDING COVERED AREA&�UCN SNAS PAT1O6.ORVEWAYS,AND WALES. ..� S. LOCATION OF WELLS WITHIN RADW&OF ONE HUNOREO FIFTY fT, <br /> ON THE PROPERTY OR ADJOINING PROPERTY, J L <br /> SEE ATTACHED ''LOCATON ASAP <br /> �i <br /> TIL .. .. <br /> ,,,.. <br /> DEPAKTMENT USE ONLY lit Appll.•II.D Aa.•pHtl By 4L .ZD _ <br /> A— <br /> Mom KRpmU.n By D.t. <br /> Pump IMA..tlnn By <br /> PE.nu.Ikn II By <br /> e/ Oas <br /> Commrmr. r <br /> 1Gc✓� I a L <br /> ACCOUNTING ONLY; AtD# FAC# ik it �J ,J� (/R A <br /> �'#L CI f� i 1. C- <br /> PS Coon FRE INFO AMOUNT KOEDTTEO CHEC"MA&H RECDYSD/Y DATE �t <br /> PERMIT!&gWICE REQUEST NUMBER INVOICE <br /> I <br />