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'APPLICATION FOR WE] ' ''UMP PERMI*` . <br /> SAK_ IAOUIN COUNTY PUB IEALTH SEI.`_CES <br /> ENVIRONMENTAL HEATH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> ' (209)468-3420 <br /> ROR•REFURDABLE PERMR EXPIRES 1 TEAM FROM UATEIS3UE0 _ <br /> (Ctngllb h TTMRahI <br /> APPLICATION IS REPS BY MADE TO THE SAM JOAOVINCOUNTY FOR A PEIOAIT TO CONSTRUCT AND/OR*STALL THE WORK DESCRIBED.TWO APPLICATION LAAOE M COMPUAIKE WITH IAA <br /> JOAOVIN COUNTY DEVELOPMENT TTTLE.CHAPTER 8.111 3.3 AND THE STANDARDS OF BAN JOAOUIN C'O�UF•I4TYBU <br /> YFOC HEALTH tE1 vtn.pAMOMMENTAL HEALTH DIVISION. . <br /> Joe A <br /> DOM 81.R AFN/`G�q IF >J l� {a�71�4 T3 S R5: N M CRY 1 F�"��� PM4:[1 KMIAPNO .'f �1-•-5 <br /> OWNER'S NAME <br /> ADDRESS PHONE 0 <br /> corrtRAeroR P n LROs PNOME'19:--/3`/4 <br /> SUBCONTRACTOR A �k7YV !4 yO <br /> J'I <br /> LIC7 PHONE/ <br /> TYPE Of WELIAVMP. ❑NEW WELL ❑REPUCEMEHT WELL ❑MONROFMO WELL S OTMER : ".! `1 <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECTREPAIR VAPOR E%TMCT"V UL/ ,I <br /> ❑N—EDP—P H.P. DEPTH PUMP IFT�rr FIRST WATER LEVEL v <br /> STYPE OF%144% ❑ y,�OUTdF•SEvrmE WELL ❑OEOPHYSICAL WELLS /�1 ac.ac— S <br /> ' ❑DESTRUCiq N: <br /> INTENDED UAE TYPE OF WELL CONSTRUCTION fPECIRCATIONS <br /> A <br /> INDUSTRIAL ❑OPEN BOTTOM pA.OF WELL ERCAVATION DUL OF CONDUCTOR CABI+O O <br /> C1OOMESTgANIVAT[ ❑GRAVEL PACRAME TYPE OF CASIMOWETLAnVC l dA.OF WELL CAST G O <br /> ❑PInLKlMVMCIPAL [:1 OR DEPTH OF GROUT SEK SPECIFICATION R <br /> C3 OOtlOATION/AG ❑OTHER GROUT SEAL NWALLED BY \ GROUT SPAM MAN[ E <br /> ❑MONTTORING GROUT SEAL M MPEO:[IY- }©} M. CONCRETE PEDESTAL BY D%LLER 11Y- El N. s <br /> AMROx.DEPTH a LOCKING CHESTER SDAISTOVE POE <br /> s <br /> PROPOSED CONtTRVCTIGRA1RllNO MSTNOD: MVD ROTARY AR POTARV AUGER CABLE OTHE11 <br /> 1 HEREBY CERTIFY THAT 1 IIAVE%SPARED THIS APPLICATION AND THAT THE WORK WILL eE DONE IN1OFS)ANCt WITH SAN JOAOUII COUNTY ORONANCEt STATEUVYt.AIARUIfSAHD <br /> REQULATONS OF THE BAN JOAOUIN COUNTY.NOME OWNER OR LICENSED AGENT'S t10MAT= TEFOLLOWINq;'T CERTIK THAT M TETE P[f1'OlIAAJICE OF TELE WORK fOR WHICH <br /> TMS PERMR IS ISSUED,I MALL NOT EMPLOY PERSONS tUeJECT TO WOROAAM't COMPpSLAWAUFO NM'CONTIIACTORS NAND OR SUS-COMMLTIMO SIGNATURE C[1RRTES <br /> THE FOLLOWTNO; -I CERTIFY TNAi M TM REIRFOF0.4ANCE OF T1fE WORK PoR WN/C}I TMS FE/IUIi M ,E IN EIsIOY PERSON SUBJECT TO woRlvAAw•I EDMFDItA7/0N LAWS OF <br /> CALIFORNIA.* TM A►PICANT MU CALL N NOW d ADVANCS FOR ALL Flamm INtACTIGRI AT 514404477.COMPLETE DRAWING AT LONER AOWA PROVIDED. <br /> 94-W x fib. TIM <br /> PLOT PUN IDr.I.ti 44.41 44.4 •ti <br /> 1.NAMES OF ITFETTI OR ROADS NEAREST TO OR SOUNpHG THE POPERTy. I.LOCATION OF HOUSE SEWAGE OWOSA1 tYTTEM OR INROPoSED <br /> 7.OUTLINE OF THE PROPERTY.OLK-M DDIRECTION.NI AND NORTH DIRECTION. ExPAA1t1ON Of SEWAGE DISPOSAL tYtT[MI. <br /> 7.DIAENSIONEO OUTt"..O AND LOCATION OF ALL EXISTING AND PROPOSED <br /> tTRUCTVS.LOCATION Of WELLS WTT11111 RAD11It OF CHI,HIUHp1ED FtTY PT. <br /> iSB,IKLVpNO COVERED ASTERS SUCH N►ATIGt.DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING P1Of.>t}y. - <br /> i <br /> L <br /> 1vo <br /> PAYMENT <br /> �FCE►UE>Z k _. <br /> JUL 9 1998 tip`` I E �::� �1iha <br /> 11 1 <br /> SAN JOAQUIN <br /> PUBUC HEALTH SERVICES - <br /> E VIP <br /> ONMENTAL HEALTH DIVISECN <br /> 1 <br /> Ink <br /> ..., ;...E .E. i . <br /> �- <br /> DOARTMINT Vol O1Qy r <br /> A..b.1—A.wl.d eT .(l A \1_t,,<n/e_ l/C Arm <br /> c D.I T <br /> 0. IYw..m BY <br /> PUT.P wlw�u.n sT D.I. <br /> owlrwll.n Nv.sll...e. <br /> i <br /> DWI. <br /> C. <br /> AEDGUNTTRO OIYtY: I <br /> E AA FKI <br /> PE CODES FEE INFO /MOUNT TTED CHECIVA:ASH RECEIVED By OATSP9KSTISLTIVIC[MOUES,RRSIYSI INVOICE <br /> P, PuD.Hee1N Sem.•Emiro.173(1/97) <br /> I J- <br />