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c�/�o v a iia <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)458-3420 <br /> X� <br /> "Ill-REFURDABIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> -�yn r��/r�T�'7-�� (ComwirtB k TrI/IICSISI <br /> AM(CATION M HERE BY MADE TO 714E SAN JOADUM C0-Vdv FOR A PERMIT TO CON/TRACT ANOJOR INET ALL TIR WORK DESCRIBED.71R0 APPLICATION I[MADEIN COMRIANCF WrTH BAN <br /> JOAOUN COUNTY OEYEE T E 8-111 B.3 TIRE!T r9 OF BAN JOAOIIN C 1R1BUC HEALTH SERVICES.ENRARONMENTAL HEALTH OPASION, <br /> Joe AOOITEBIIA • cm rAII[EL R12EIAPN/ -Q <br /> OWNERS NA AGGRESS 1;♦OrI[ <br /> CONTRACTORI\atuc -atlDn k�)llow,UC• �T'NONE � �✓VV <br /> SVSCONTRACTOR ADOM96 UC• PHONE/- <br /> TYPE OF WELIRUMP; ❑NEW WEU TL-'lT REPLACEMENT WELL ❑MOMTOWNO WELL 1 ❑OTHER <br /> ❑NBT�AyI(J,A710N Ll WEL!��IYB7EM REPAIR ❑CROS"OHNECT REPAIR ❑VAPOR EXTR ACTgN WELL F J <br /> ❑N jl/WNY H.P. rJC DEPTH NMP BET FT. FIRST WATER EFVEI O <br /> OYK OF PJMF7 \+ <br /> `711 ❑01ITOF-SERVICE WEIl ❑GEOPHYSICAL WELL• ❑ ROIL Bomma <br /> {./DFSTEtUCTgN: <br /> 107 rm OF WELL WNSTRUCTION SPIECIfICAtIoNAS <br /> A <br /> 0114MVIRAL ❑OPEN BOTTOM OUL OF WELL EXCAVATION DIA.OF CONO JCTOR CARDIO p <br /> ❑DOMESTICFW VATE ❑ORAVEL PACKISRE TYPE OF CABINGISTfEUPVC 1„A.OF WELL CASINO O <br /> ❑PRgj13 DW <br /> CA0.RlCIPAL VEN DFPTHOF GROVT SEAL SPECIFICAi ION q <br /> C3BUIIOA7IONIAG 11 OTHER INSTALLED ORT REAL STALLED BY GROUT BRAND NAME E <br /> ❑MoNRo10N0 OPIOUT SEAL MMFEO:❑Yr ❑N. CONCRTE PEDESTAL BY OWLLER:❑Y- [IN. S <br /> AP X.DEPTH LOCKING CIIES7r”SOXAFTOVE TYRO B <br /> PROPOSED CONSTRUCTIONIMUING METHOD;LR1D ROTARY AIR ROTARY AUGER CML! OTHER <br /> 1 HERM CERTIFY THAT 1 HAVE FEEP^WD TMS APPLICATION AND THAT THE WORK WRL M 1100E N ACCORDANCE WITH MN JOAOUN COIMTY OR OMANCES,STATE LAWS,AND ARES ANO <br /> REGULATIONS OF THE SAN JOAOUIH COUNTY.HOMO OWNER OR UCENSFO AGENT'S SIGNATURE CEMN'rES THE FGU.OVAM:'I CERTIFY THAT IN THE PERFORMANCE OF THE voow FOR WHICH <br /> THIS PERMIT 10 IRSUEO,1 SHALL NOT EMPLOY PERSONS MJECT TO WO/OOAAWS CGMPWSATION LAWS OF CALWORXA.-CONTRACTORS FIRING OR BUD-CONTRACTING SgNATURE CERTIFIES <br /> 171E FULL -1 CCITTIFY TNAT N THE PERORMA"CE OF THEE N/OIK F�Tl <br /> WMICN THIS PENdITT'b ISfIIED.1 SHALL EMPLOY 1'EIYOIIS SUBJECT TO TYOIIgAAR't COAMdSARON HAWS OF <br /> CALJPO HIE A PU ANT WT C HIO q ADVANM ALLEOTIOMAf2IS1 ./AXf.COMPLETE dNWINO AT LON4J1ATEe WI 8a•I. 't. <br /> 1,NAMES <br /> OF STREETS OR ROADS NEAREST TO OR BOUNOOA THE P IDI'E/RTV. OC AIION Of GgI1BF SEWAOE OHSPOSAL 6YST[M OR PIIpIq BEO <br /> 2.OVTUNE OF THE PROPERTY.GIVING DMENSIONS AHO NOW"OMECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.OIMOMONEO OVTLINFS ANO LOCATION OF ALL EXRSTNG AND PROPUBEli S.LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY R. <br /> STINCTVIEI.NCLUONO COVERED AREAS WCH AS PATHS,DRIVEWAYS,AM WALKS. ON THE PROPERTY OR ADJOPWM PROPERTY. <br /> .. ..... .. <br /> ............. ... <br /> . .. •.... <br /> PAYMEN <br /> a AUG s 1999 Z <br /> r .. "E4LTN 61NTY <br /> LlG4 l'S <br /> ' RVIC S <br /> ENVIRONMENTAL HEALTH O,V"014 <br /> AW-I..A-W d By DH. 3 ( �• A.- y <br /> a• H,wH...HI.n BY - -- OHS. P."AVP '_BY. <br /> nr,..etbn FwP.ene..ar Do <br /> ACCORNIPM ONLY: AHD/ FAC! <br /> PE CODES FEE INFO AMOUNT REMITTED NECR/ SN RECISM By DATE Pow"I"F2NICr REDL1rBT MIMSSI INVOICE <br /> 3 D,i SO 8/3 <br /> Pub Hea"SGrv.-Emmo.173(1/97) <br />