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APPLICATION FGA Wn,.LIPUMP PERMI'* <br /> S�AQUIN COUNTf PUBLIC HEALTH S- <br /> ENVIRONMENTAL aEALTH DIVISION— CES <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 9520 R G A' /� v / <br /> (209) 468.3420 1 V/L-t <br /> MOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OAYE ISSUER LFII■/�N /`�, \ � <br /> APPLICATION IS NE,E BY MADE TO THE SAN JOAQUIN Cot)"FOO A 1 Y �'. l��.E <br /> JOAOUIN COUNTY DEVELOPMENTICBmpMR In TTipI_ _ fff • ■ • V V <br /> PERMIT TO CONSTRUCT ANO,On INSTALL THE WOR(DESCRIBED.THIS APPLICATION i6 MADE IN COM <br /> TRIF,'CHApTER 8-7116.3 AND THE 6TANOAROB OF BAN JOAQUIN COUNry PUBLIC HEALTI16FgVICEe,ES APPLICATION <br /> HEALTH IN COON. <br /> JOB ApORE83/Oq APN/ 76 n <br /> ,(' COMPLIANCE NrtTHH/ <br /> OWNER'S NAMEy /�rS Dr9 Cknuf �e r <br /> 1>au /d T, qZgd fi 5 AIa "'ys ('1����CITY <br /> CP( LFT' / i vu Pl 1 Bey, /1 PARCEL SIZE APNI� <br /> MI v f <br /> CORgCTOR F ApOREBv�m J �/ '✓��P UOOp(, <br /> Pv 9s�coP ip � ✓ -- <br /> Run CONTgACTOR , p dr , ADDRESS PHONE fy9/ P <br /> SOC <br /> ADDREBB uc#— PHONE I <br /> _sCnT �Fd a CIA fl <br /> TYPE OFLICE �— <br /> —y,,EL�Mp. Rr NEW WELL 'S/ PHONE <br /> W ❑ RERACEMENT WELL <br /> INSTALLATION ❑WELL SYSTEM REPAIR MONITORING WELL I <br /> N A O N. 0 ❑OTHER <br /> gWeb ❑ CROSSCONNECT REPAIR <br /> RYFE OF PUMPI H'p' ❑ VAPoR EXTRACTION <br /> DEPTH PVMP 6ETFT. WELL <br /> -UT-DF-SERVICE WELL FIRST WATE6 LEVEL <br /> I]DESTRUCTION� � ^EOC)b61CAL VJELLi � O <br /> 601E BORING 0 <br /> INTENDED USE B <br /> TYPE OF WELL <br /> ❑ INDUSTRIAL ❑OPENBOTTOM CONfl 11 1 16PECIFICATION6 <br /> OOMESTICRYBVATE 10 DIA.OF WELL EXCAVATION /n'/ <br /> laI DRIVEL PACK/SIZE ��— DIA.OF CONDUCTOR CASING A <br /> RIBUCRAUNICIPgI �p,aMN TYPE OF Cg61ND/6TEEIB+yC SC� q <br /> ❑ IgRIGATgN/AO ❑OTHEfl DEPTH OF GROUT SEAL SQ�� DIA.OF WELL CASINO /p/ D <br /> ����_ SPECIFICATION <br /> -� D <br /> ® MONITORING GROUT SEAL INSTALLED BY ,�Fv'��B r <br /> �---_� Grow Sml,,O I`, -------- C1IPmq ITT E_NG E <br /> APPROX.SEPT" O GROUT SEAL PUMPED: ®Va ❑Ne CONCRETE PEDESTAL BY pRILLER:yy Y. <br /> ❑Ne S, <br /> PROPOSED CONATgVCTION/pRLUNa MEROD: MUD ROTARY LOCKING CHESTER BOX/STOVE RPE_Ups' <br /> AIR ROTARY AUGER �/7� 5 <br /> _yam CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOPK WILL BE DONE IN ACCORDANCE VATH BAN JOAOUIN CO VNTY OgpINANCE6.STATE UWe,ANO RULER wHD <br /> REGULATIONS OF THE SAN JOADVIN COVNTY, <br /> T's <br /> T1/16 PERMIT IS 161UED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOgNIA.' COMMCTOR'B HIRING OR BUBLOMFI CE OF HE NATURE CERTIFIES <br /> ROME OWNER T LICENSED AN'S CO PENSATIO CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFOrIMANCE OF THE WOR(FOR W511CN <br /> THE FOLLOtMNp: 'I CERTIFY THAT IN TILE PERFORMANCE OF THE WOR(FOR WHICH THIS PEWIT IB ISSUED,1 SHALL EMPLOY PERSONS SVBJECT Tp WORRMANY COMPENSATION CALIFORNIA.' THE APPLICANT MVBT CALL 21 HOW IN ADVANCE FOR ALL REOIARED INSPECTONF AT IZOEI44141 . COMPLETE DMWIO AT LOWER RK A N'S CIDER. <br /> SIv,wJ% :'moi LAWS OF <br /> 1 <br /> TlliePLOT PLAN fGNN,I. .. D.re <br /> V <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO on BOVNpINO THE FROTFRTV�HaI Buela <br /> 1e , <br /> 2. <br /> OF THE <br /> NSIONS <br /> G. OIIIAEN6EONE0 DMLINF6 ANO IOCATONEOF All EXISTING NORTH <br /> OAND II PROPOSED A. LOCATION OF HOUSE SEWAGE AL syBAL SYSTEM OR PIbPo6ED <br /> STRUCTUnE6.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WADS. EXPANSION OF SEWAGE DISPOSAL S OF O B. <br /> S. LOCATION OF WELLS WNNIN MOLLIS OF ONE HUNDRED FIFTY <br /> R. <br /> ON THE PROPERTY OR AOJOININO ROPERTY, <br /> ........:...... <br /> DEPARTMENT USE ONLY <br /> Applleenen Aveepled BY <br /> Z 4 <br /> Due <br /> O,em rnP«nen Br <br /> Olt,. <br /> PvnP Inrp«nun By <br /> Oe.mrnen Inn«non er Dne <br /> Cemman. � � Due <br /> Dc -O 6 <br /> ACCOUNTING ONLY; AIDS <br /> FAP. 5' oi(a3i8-�F3 <br /> PE CODES FEE INFO AMOUNT"EMITTED CHECKNMASH RECEIVED BY <br /> 2 D tt ,,--••,, GATE PEIEAITgFgV CE REDDEST NUMBER INVOICE <br /> Pub.Health Sely.-Enviro.173(1/97) <br /> 51`x. <br /> 9 <br />