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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKMR CA 95201588 <br /> 1209)488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APMfCAI ION IS IIERE By MADE TO THE 9Au lcomp1@EI M TPIpREBEFI <br /> JOAGLAN COVNiV FOR A PER/AIT TO CONSTRUCT ANDMA INSTALL THE WOPK DESCRIBED.THIS APPLICATION 1S MADE IN COMM LANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOPMENT IRLE,CHAPTER B-1 11 S.3 AND It BfANDAROe O SAN HOUR!COUNTY PUBLIC HEALTH SERVICER.ENVBIOtMENTAL HEALTH DIVRIC% <br /> Joe ADDREazn;i <br /> S) <br /> CTJ J PANG I=E"a <br /> OWNER'S NA `'PHONE ACONTRACTOR �f <br /> A001119a C <br /> BUB CONTRACTOR C/ <br /> ADDRESS UCJ H10NE/ <br /> TYPE OF WELL/pUlw• ❑NEW WELL ❑RFPLACEMENTµ[LL ❑MONRORNlG YYELL <br /> ❑INBTALLATKDN ❑OTHER <br /> ❑WELL SYS M REPAIR Q CR095CONNECT REPAIR ❑VAPOR EXTRACTION WELLA <br /> C}N"" k H P DEPTH rump Bim��////OFr, <br /> r>YPE OF PUMH ` 'y1� FIRST WATER LEVEL p <br /> ❑OUT-Or'SERVICE N4LL ❑OEOMIYSICAL WELL A ❑ SOR BORNO <br /> A <br /> DESTRUCTION; <br /> INTI DED USS IYPEO WFll CONSTRIIC NfPECEIC ION{ <br /> ❑INDUSTRIAL ❑OPEN BorTOM A <br /> ��( A.OF WELL EXCAVATION CIA.OF CONOUCTORCARINO <br /> �21L OOAIE971CryryVATF. ❑GRAVEL PACKJBIIE —�- O <br /> TYPE OF CASINGMTEELIPVC DIA OF WELL CASINO <br /> Q HIBLK:AAVN[CI!`AL ❑DRIVEN D <br /> DEM14 OF GROUT SEAL S"ECNICATION <br /> 13"'a <br /> mR10AF"HIAO ❑OTHER A <br /> GROUT SEAL INST PUMP FLED BY GROUT BRAND NAME <br /> ❑MONITORING OgOtrT REAL PUMPED:❑Y. ❑N. E <br /> APMO%-OIPTH CONCRETE PEomm.BY DRILLER:Q Y— CIN. S <br /> LOCKMO CHESTER BOKJBTOVE PIPE <br /> HIO PO EED CONeTRVCRON/pryWNO METHOD:""POTAM ^-- S <br /> _ AIR ROTARY AUGER _CARLE OTHER <br /> HMSY <br /> 1 EGULAT CERTIFY THAT I HAVE HIW Coo THIS ArME tvyIOH AND THAT TIE WORLµTIL BE DONE M ACCORDANCE WITH BAN JOAOURN COUNTY ORd HANCES•STATE LAWS,AND NREM AND <br /> REOVLAT/rT'OF THE SAN)ktL fl RI COUNTY.NOME OµTIER Oq LICENSED AOF,AIT'I SIGNATURE CERrIFIE9 THE TOLLO'NMo:•1 CERTIFY THAT IN THE PERfOpMANCE OF Ti IE WOR(FOR W/IICN <br /> 11118 PERMfT 1S 1@SUEb,1 SHALL NOT EMPLOV P£RBone eUBJEt TO WORKMAN'S COMPENSATION LAWS OF CAL A.-C!'I CER TOgT AT IN OR SV&CONT NCE Of SIE WORK E R w"wN <br /> THE FOLLOYAlKI; THAT 7N Tf1E PERF ANCE TIK WOFX FOR WN1cH TNR PERMrT re IeaUED,I @HALL EATPLOY IERSONB eIN1-IECT TO WORKMNI•E COMpEH ICON IAWe OF <br /> CALIFORM APMI MT MUST CA1L] {IN ANCE FOR ALA REGUARM p <br /> TIONS AT I�OIt ASAs.]],COMPLETE d1AWtF.iO AT LOWER AREA HIOVpED. <br /> BkMd x _TIII. fP,5 <br /> O.t. <br /> 1.NAMES OF PLOT PUN IDr—I.M.f.l I..I/ l.� <br /> STREET/OR ROAbe NEAREST 70 OR BOUNOINO THE pAIIPERfY. _ A. LOCATION OF ffOVeE SEWAOF DISPOSAL SYSTEM OR rNiplgeEn <br /> _'OVfLINE OF THE PROPERTY,M"'N'DIMENSIONS AND NORTH DRECTRDN- <br /> �.DRAENBIONED OUTLINF,a AND LOCATMN OF All EKISFAM AND PROMSEO EKPANMLON or IMAGE DISPDSAL eySTEMS. <br /> BTRUCTVRES,INCLUCOM COVERED APEAB SUCH AS PATIOS,ORIVEWAYB,AND WALt@. B-LOCATION OF WEIIS 1MTHIN RADIUM OF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOIMNO PAOPEII'tt. <br /> {a\ - .. <br /> �. . .. ' PAYMEt <br /> :. .... <br /> V..'. . . . <br /> : ......_; .. . ;... . ...� <br /> :,JUN.,1:0.1997 <br /> _ <br /> ... ... ; <br /> SRN ln- <br /> »Jla <br /> r...:........: ..:.. ?... - <br /> ,...; E LSER`lIlIEEISI <br /> i EµVtRrJINNi IJT:•,i. 1' <br /> DE►/WTAIENT USE ORLT <br /> ASI--11-A...Pted By t ~ <br /> b.lA E+wx11e.19y D t pV,,, I / r/ <br /> •2s/ <br /> D«. <br /> � Crw..nwN.•____ <br /> ACCOLAITINO ONLY; <br /> Alb# FACS <br /> PE CODE@ FEE INTO AMOUNT IIENKTTED IIECK/CASH RECEfVSD IY DATE -J <br /> INDUd1T1SFNVICE REQUEST N[]AB INVOICE <br /> C) C <br /> Pub.HBBIth Serv.-ERYirb.173(3/96) <br />