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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MAY 2 0 1999 <br /> ENVIRONMENTAL HEALTH DIVISION _ <br /> 384 EAST WEBER AVENUE, STOCKTON, CA 952{* ,� � ;;;�DOIS <br /> - 1'a I -,?=AL(H <br /> (209) 4683420 �'rHlui �`� <br /> RON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Compkia In TripneStal <br /> APPLICATION IS IREPIE BY MADE TO THE SAN JOACKM COUNTY FOR A PERMIT TO CONSTRUCT ANOAR INSTALL THE WORK DESCRIBED_THIS APPLICATION Is MADE IN COMPLIANCE WITII SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER`�Or-1 i 15-3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUB�LLIIC.HEALTH SERVICES ENVIRONMENTAL HEALTH UIVIGION <br /> JOE'ADOREBB/OR APHI 7r l?a!U CrTY 7/A��/� !/r{� Cy� PARCEL SIZEIAPN. <br /> OWNERS NAME ADOREOU '� D d PHONEI <br /> CONTRACTOR lI' ✓M� ADOREBR�'�c/� j�/W l� rW / —UC N�yS�n? T PHONE 1,4z <br /> / <br /> 6Uw CONTRACTOR ADDRESS 6�" 'G LIC,: <br /> TYPE OF WELL1PUMP- jK NEW WELL ❑ REPLACEMENT WELL ❑ MONRToPYNG WELL r ❑ OTHER <br /> ❑ INSTAyLLATION ❑ WELL SYSTEM REPAIR ❑ CROes-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 1 J <br /> ❑ <br /> N.❑RrO.M H P- DEPTH PUMP BET FT FIRST WATER LEVEL O <br /> (TYPE OF PUMPI8 <br /> ❑ OUT-0FBtTIVICE WELL ClOEOPHYBICAL WELL 0 ROIL BORrNO <br /> ❑DESTRUCTION! '"^ •L <br /> A <br /> INTENDED USE TYPE OF WELL CONSTRUCTIDN SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DEA OF WELL EXCAVATION [}//'r _ DIA OF CONDUCTORCAMNO Er <br /> ❑ DOMESTICIPIUVATE ❑GjtAVEL PACXIUIZE TYPE OF CA32NOMTEEUWCr� Y 01A. OFWELL CASINO a <br /> ❑ PUSUC/MUMCIPAL ❑-}DRIVEN OEPYH OF GROUT SEAL 96-+, �0 , SPECIFICATIONS T'7� jr <br /> ❑ 1RRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED OUT BRAND NAME /lJf7Ll(/[/ E <br /> .KMWOTOPING ! GROUY SEAL PUMPED- ❑Y.. &4- CONCRETE PEDESTAL BY ORILILR ❑Y— ❑N. s <br /> APPROX DTPTH LOCKING CHESTER SOXISTOVE PEPE s <br /> PROTOSED CONSTRUCTIONMmLi]NG METHOD MUD ROTARY AIR ROTARY AVOER__,-�_CABtE OTHER <br /> Y CERTIFY THAT i HAVE PREPARED T1416 APTLICATION AND THAT THE WOW WILL RE DONE IN ACCORDANCE WITH CAN JOAQUIN COUNTY ORDIHAr4CES STATE LAWS nWD RULES ANI(::� <br /> TIONS OF THE SAN JOAOUIN COUNTY HONE OWNER OR LICENSED AGENT 9 SIGNATURE CERTIFIES THE POLLOWMO 1 CERTIFY THAT iN TWE PERFORMANCE OF THE WOW FDR WHrCN <br /> TAR PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS BUIIIJECT TO WORKMAN S COINPETISAVON LAWS OF CALIF(3f"A_ CONTRACTOR 9 HIRING OR 8UBCONTRACTRIO SIGNATURE CERTIFIES <br /> THE FOLLOWING 'I CERTIFY THAT r"THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 IBSUED I SHAH EMMOY PEROONS 9URJECT TO WORIONAM S COPAPM&ATION LAWS OF <br /> CALIFOP"A A T CALL Z4 NO IN ADVANICIE FOR ALL REOUNtm INSPECTIONS AT I29911S�SJR2] COMPLETE ORAWIW6 AT LOWER AREA PROVIDED _ <br /> ei9n.d X TM. D.t• �� <br /> PLOT RAI'!ID..w I.Be.I.I Se.l. 'to <br /> 1 NAAIEB OF STREETe OR ROADS NEAREST T BOUNDS.THE PROPERTY 4 LOCATION OF HOUSE REWAOE DISPOSAL SYSTEM OR PROP06EO <br /> Z OUTLINE OF THE FROPERTY OIVING DIMENSIONS AND WORTH DIRECTION EXPANSION Of SEWAGE DISPOSAL SYSTEMS <br /> 3 DIMENSIONED OUTLINFt AND LOCATION OF AM EXISTING AND PROPOSED S LOCATION OF WELLS WrtUIN RADIUS OF ONE HUNDRED FIFTY FT <br /> BTAUCTUREB MCLUDINO COVERED AREAS SUCH A$PAT#OS DRIVEWAYS AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY <br /> dam- <br /> IL ! <br /> 13FPAAVMENT USE ONLY <br /> AvPII..,Ien Aae.vl.d nY .. <br /> O.oax ln.peeebn BT <br /> D.I• P-0 I—P-11en Sy Dot. <br /> PLY <br /> *rOUNTINO ONLY AIDS FAC! <br /> pE CODER FEE INFO AMOUNT REMITTED CHECKI:CABI RECAVED SY DATE PEOA TISERVICE REOUELT III.RIBOt INVOICE <br /> 3501 7-00 - S a <br />