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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBmpIEIE M TTIpREE1E1 <br /> APPLICATION 1911EPE BY MADE TO THE BAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORE DESCRIBED.THIS APPLICATION IS MAGE IN COMPLIANCE Wflll SAN <br /> JOAQUIN COUNTY DEWLOP¢¢MEENNT TITLE.CRATER 9-11115.3 AND THE STANDARD OF SAN JOAWIN COUNTY PUBUC HEALTH SERVICES,ENVIRONMENTAL NFALTH^MSIQ� AC1 �( <br /> JOB ADDREBBOA A. /U V I v ed' HW• ` ( T F�� Cm W I�( PARCEL SIZFJARIas/M1VaMMt'7_04� <br /> _ �p ( / 6 ck 1t, 333 -1iI�n <br /> OWNER 9 NAME/(QR a C�A.J"t-RV CT'JtL �MP•��/ AGGRESS 2[ �rT_� "`TRb E o <br /> CONTRACTOR 614VL/`J ZE2O r[KALL S LS rev-e—, AIRREBB +'9 �� / C 9 SS�D ucl J��3 PNow 1,939—M O <br /> BIR CONTRACTOR ADMESS MIT I'NOWI <br /> TYPE OF WELLMUMP: ❑ NEW WLLl ❑ REPLACEMENT WELL ❑ mommomNO WELL 1 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL 1 J <br /> ❑N_❑NIPW N.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL O <br /> RYFE OF MMPI n <br /> ❑ DVT-OFBERVK:E WELL ❑ GEOPHYSICAL WELL 1 BON BOPoNO 10 B <br /> ❑DEBTPUCTION <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTIBAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ OOMFSTICIRNVATE 1:1 GRAVEL PACK/mZE TYPE OF CASINGRTEELRVC IRA.OF WELL CASINO O <br /> Cl PUBLICIMUNICNAL ❑DRIVEN DEPTH OF GROUT MAL SPECIFICATION R <br /> ❑ IRRIOATION/AG ❑OTHER GROUT BFAL mTAl1ID BY GROUT BRAND NAME E <br /> ❑ MONITORING f GROUT SEAL PUMPED: ❑Y.. [IN. CONCRETE PEDESTAL BY DRILLER:❑Y- [IN. 5 <br /> AI OX.OMH IO LOCKING CHESTER BOKroTOVE{7PL ��'f'X�Z� S <br /> MOPOSED CONSTRUCTR NNRR <br /> LUM METHOD: MUD ROTARY AIR NOTARY AMEN CABLE OTHER ✓Aikjt i i\ <br /> I NEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATIQN AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGIMTIONH OF THE BAN JOA- C0 HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTMIEB THE F LLOWIMG:'I CERTIFY THAT M THE MI FOR MANCE OF THE WOR(FOR WHICH <br /> HAS PERMIT 19188 D,I S/ALL NOT OY PERSONS SUBJECT TO WORKMAM'8 COMPENSATION LAWS 11 CALIFORNIA.- CONTRACTOR'S HONING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOW : •1 ERTIFY THA M N PERO lE-WgRC.FOP WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PEROONS SUBJECT TO WOAXMAM'S COMPENSATION LAWS OF <br /> CALL'opook ;FIE A PUCBT M CAISh 1 AMCE FOR ALL REQUITED INSPECTIONS AT ILNRI Itl-B1If. COMPETE DRAWING AT LOWER ATEA PRO DED. <br /> NPS X � 3t) <br /> ROT MR RN.w 1.SP.I.I 8e1.�_•le D L/L1 <br /> 1. NAMES OF STREETS ON ROADS NEAREST TO OR BOUNDING THE R WRY. 1. LOCATION OF MUSE SEWAGE D UIMSAL SYSTEM OR RIDIOBED <br /> S. OUTLINE OF THE PROPERTY,OTAM ORAENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> ]. INMENMNED OVTUNF8 AND LOCATION OF ALL EXITING AM FHOMSED E. LOCATION OF WELLS WITHIN RADIUM OF ONE HONORED FIFTY FT. <br /> STRUCTURES,INCLUOINO COVERED AREAS MUCH AS PATIOS,DRIVEWAYS,AND WALXe. ON THE PROFERTY OR ADJOIHMA m DKK. <br /> l D <br /> C N <br /> 5. _ Ham vti,(s•z <br /> 3 a� eY �e <br /> 2 _ <br /> I <br /> A«wlen B <br /> AvorMENT use ONLY <br /> r y/� <br /> nenbn - G `-'/ AM, <br /> Greur lrnpegrbn Br D.r. <br /> P 1n.P«nen By D.I.- <br /> ACCOUNTING ONLY: AIOI FACT <br /> PE CODES FEE INFO AMOUNT REMITTCKMASH RES DATE PERMITISM"CE REQUEST NWNM INVOICE <br /> 2 '!�3 qF or) <br /> `l S .00 DD <br /> Pub Health Sely. Enviro.173(1/97) <br />