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If <br /> APPLICATION FOR WEWPUMP PERMIT / <br /> SAN JOAQUIN COUNTY PUdUC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 458.3420 a RIGINAL <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete Is Trl'Beital <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AMIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1115.33 AND THE BTANOARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICER.ENVIRONMENTAL HEALTH DIVISION. (� <br /> JOB ADOREBS/OR/�APHO f',(/J 3� `�ac:./q _ (/7�ti.IP�1 1 a CITY, l�j�r.k t�' /n ^��J�� PARCE/Ly,S{WAPNI • 0b -- <br /> OWNER'S NAME i ly1 1 C'_I ti1 l� j��`t '..].,[ L .1'I ��AODREBS�•C t• SS[j�F�- � �YI I�L.iYV1� •(.7T PHONE I <br /> X CONTRACTOR (y�O: \N ��1 \01/�,%CA 4�M` ' 7� f 11 AOOiEBS J UR LI/Cy'/ P70 <br /> 60" <br /> CSI...CONTRACTON, l - _PHOXNE <br /> TYPE OF WELL/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONTORING WELL r ❑OTHER <br /> ❑ iNwrAu A-noN ❑ WELL SYSTEM REPAIR ❑ CROSS-COHNECT REPAIR ❑ VAPOR EXTRACTION WELL• J <br /> ❑is.. ❑P.P.I. H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PHMPI <br /> ❑ OUT-oF-SERVICE WELL ❑ GEOPHYSICAL WELL) 80IL BORING <br /> ❑DESTRUCTION- <br /> INTENDED USE TYPS OF WELL CONSTRUCTION SPECIRCATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION , INA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTIC/PRIVATE - ❑GRAVEL PACXMZE TYPE OF CASING/8TEEL/PVC DIA.OF WELL CASINO O <br /> ❑ PUSLICANUNICIPAL ❑DISVEN DEPTH OF GROUT SEAL SPECIFICATION 4 <br /> ❑ MVGATION/AG 13 ow GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> 0MOWTORING GROUT SEAL PUMPED: ❑Y. ❑N. CONCRETE PEDESTAL BY DM1Mt❑Y. ❑N. s <br /> APPROX.DER. LOCKING CHESTER SOXMTOVE PTFE s <br /> PROPOSE! CONSTRVCTION/DIR M METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE-EBY CERTIFY THAT LAVE PREPARED THIS APPLICATION ANO THAT THE WORK WOOL BE DONE IN ACCORDANCE WITH SAN JOAOUIH COUNTY ORORNANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIII COUNTY. 140ME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOW1N0t•1 CERTIFY THAT M THE PEIiORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT M ISSUED.I @HALL NOT EMPLOY PERSONS SUBJECT TO WOIIKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S ISISNG OR SUB-CONTRACTING SONATURE CERTIFIES <br /> THE FOLLOWING: *I CERTIFY THAT 1N RR./ANCE OF THE WORK FOR WHICH THIS PERMIT IS 189UED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.-.TIRE APPLICANT MUST CAlL,44 HOURS IN ADVANCE I"ALL RZOUIRED WSPVCTION_S AT 12051400-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> S10n.d X TIN. 0.1. . <br /> PLOT FUN IDt.w t.Se N ee.1. •h <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTTUSrt OF THE PROPERFY,OPA NG DIME.SION8 AND NORTH DI OCTION. EXPANSION OF SEWAGE ONIPOSAL SYSTEMS. <br /> Ir...w.s.�d.tt.Y��.d.aLLneYt/ts Y�.,tt0!'!>ab,��if Mgl.N,.. .. _,... -...__....... .......i...I,NM'.�TIItN ItsYgN•t.igNW 4WtiK/KlrR.MM�gii/}LNcrY,Fi.. <br /> .:......: .. .. ........i.. .. ..y..... .....+u..... ... ...... ..... <br /> . .... .. ........... .............................. ........ ................... <br /> DEPARTMENT USE ONLY /- - <br /> AAl1.Nbn A—st.d By O.N. Atw <br /> Ov-A hwP-16.. Sr O.t. P"'.0 1r.0 0."By DN. z, <br /> De.t—d-In.p.otlen r - DN. . <br /> IF <br /> C.� <br /> • <br /> ACCOUNTING ONLY: AM# FAC/ - <br /> K CODES FEE INFO AMOUNT REMITTED CHEC/VICASH pigggim SY DATE F9S61ITtsumCE REOUEST NUMNEI INVOICE <br /> Pub Health Serv.-EEnviro.173(1/97) <br />