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05/0"./2003 09:43 2094683, FIFTH FLOOR PAGE 02
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<br /> APPLICATION F R W UPUMP PERMIT
<br /> SAN JOAQUIN COON PU'LIC HEALTH SERVICES
<br /> ENVIRONMEN LH LTH DIVISION
<br /> P 0 BOX 388, 445 N. SAN JO QUIN T., STOCKTON, CA 95201.388
<br /> (20 488• 20
<br /> NON-REFUNDAVLE PfRMIT FIRES YEAR FROM GATE ISSUED
<br /> (Campy in Tr licata)
<br /> APPUCATwN IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMrrTO CONSrRU AND R INSTALL THE WORK DESCRIBED-THIS APPLICATION Is MADE IN COMPLIANCE Wary SAN
<br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN N COUNTY PL
<br /> HEALTH SERVICES,ENVIRONMENTAL,HEALTH DIVISION.
<br /> JOB ADOREBS(DRAPNsar7 r }y �V115941»V2 ✓4"N-+d Lr'
<br /> CITY ZrQA,4Z4Y � PARCEL eIZ�E/APSN/
<br /> -"-2- -13
<br /> .
<br /> OWNER'S NAME / 6 ,'eAl ADDRESS .O.B 6 •• -0&wLI G 9� PHONE f
<br /> CONTRACTOR q/O »
<br /> AODREss I�} �c/t�2rt�' ,LlCA_r�6C0.S�'�' PHONES
<br /> Sus CONTRACTOR PJJtiJAC A.21lJ�"
<br /> ADDRESS LIC7 PHONE/
<br /> TYpE Of waxrnuMp: ❑NEW WELL E3 REPLACEMENT wELL ❑ MONrroAING WELL/ ❑OTHER
<br /> ❑INsTAUJATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL a
<br /> (TYRE OF—PUMP)
<br /> ClNow CJ Rw.ir H.P. DEPTH PUMPSET FT, FIRST WATER LEVEL_ 0
<br /> �f
<br /> ❑
<br /> OUT-0F-SERVICE WELL ❑GEOPHYSICAL WELL• Yfl,Ib{J SOIL BORING 12 LF.�
<br /> ❑oESTRUCTbN: fff����� t "az
<br /> INTENDED USE TVPQ 0 WEll CONSTRUCTION SPECIFIC p
<br /> ❑ woU6TR1AL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION f"z/ k- DIA,OF CONDUCTORCASING 0
<br /> ❑ bOME4Tn/MVATE ❑GRAVEL PACK/59E TYPE OF CASINGISEEELIPVC_ ,1 A DIA,OF WELL CA&NQ 0
<br /> ❑PUBLIC1 umcIPAL ❑DRIVEN DEPTH OF GROUT BEAL- SPECIFICATION p
<br /> ❑IRHIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E•
<br /> ❑MONrroRING / GROUT SEAL PUMPED: ❑Yr o CONCR[TE PEOESrAL BY DFULLF,t❑yw ❑N. 5
<br /> APPROX.DEPTH f� ��yr+5� LOCKING CHESTER BOX/STOVE PIPE
<br /> PROPOSED CONSTRUCTIONIORILLINO METHOD: MUD ROYARY AIq ROTARY AUGER CABLE OTHER 8L^GT ,41Yy6
<br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL GE DONE IN ACCORDANCE wrTm SAN JOAQUIN COUNTY ORDINANCE6,STATE LAWS,AND RULES AND
<br /> REGULATIONS OF THE SAN JOAOttlN COUNTY. HOME OWNER OR LICENSED AOCNT'S SIGNATURE CERTIFIES THE FOLLowING:'I CEKTIFYTHAT IN THE PEAFOFWANCE OF THE WOW FOA WHICH
<br /> THISPERMR IO ISSUED,I GNALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOANIA,' CONTRACTOR'S HIRING OR SUBCONTRACTING S1ONATURE CERTIFIES
<br /> THE FOU.OWINO: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHAIJ,EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATWN LAWS OF
<br /> CALIFORNIA.' CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL RGOIARED IIWPECTIONS AT(200)4",Z*23. COMPLETE DRAWING AT LOWER AREA PROVIDED.
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<br /> PLOT PLAN ID...+to 5ca1.1 S..I, 'u
<br /> I. N 9 OF STREETS OR ROADS NE ST TO OR BOUNDING THE PROPERTY.
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<br /> DEPARTMENT USE ONLY
<br /> APPIko•"Aoaptd By �A�'L�Ai1s�'(N/S� Doto Ama
<br /> Crota kopec on BY Doa PtnP Inpxtlon Br Date
<br /> Dalt.
<br /> Oatruotlan Yal•o..tL..BY ����.,��� /�
<br /> cam,Pt.n7al:
<br /> AGCOUNTutO ONLY: AID1 FARrr
<br /> PE COOSa FEE INFO AMOUNT REMITTED CHECKSICASH FIECOVE0 Y OATf 0SWIT/SDWICG PAQV95T NWADCR INVOICE
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