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i <br /> APPLICATION FOR WELL/PUMP PERMIT ,�► <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES 44 <br /> ENVIRONMENTAL HEALTH DIVISIONyr <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)4683420 .Y <br /> NOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED U85_ i,^O Y ` <br /> 1 <br /> (Complete IR Tf1pBnte) J lY <br /> APPLICATION 19 MM SY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCNBED.TIIIS APPLICATION 19 MADE IN COMPLIANCE WITII SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 0-111 6-3 AND THE Sr ANOMOS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SEIIVICEB,ENVIRONMENTAL HEALTH DIVISION. <br /> 1 Z3 1�GL�+t!C ✓ cm A)e'(( PARCEL RIZFJAPN' L 9� <br /> JOe ADbFKR9A]R APN/ `� � �/T- /��T <br /> OWNE R'B NAME l , /' ADORE9B (�'[1/-A •'S,I i� ��V I'IONE• {/1 1w <br /> CONRRACTOR pkyvi-✓ ADORESB `1ZJ�al� UC/ RIONLz1� 31-ggaT� <br /> SUBCONTRACTOR Al,omee UC/ PHONE' <br /> TYPE OF WELUPLIMPI ❑NEW WELL ❑REPLACEMENT WELL ❑MONITOORI�NO WELL• ❑OTHERINSTALLATIO `E <br /> &DEE IMI <br /> ❑N.w❑RePMrN ❑WELL SYSTEM REPAIR ❑PTH pp- -� I T E. 4 7L vh ._ E D <br /> IN <br /> HYPE OF PVMPI 1 <br /> >�O UT-OF-SERVICE WELL ❑OEOATY"9 fna tve e II CU WI1l IUUL B <br /> LJ OEBTRL1CTLoN �being cuinnieled <br /> ���Y u� <br /> work xr,r: a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIflO TION, _ A <br /> ❑INDUSTRIAL ❑OT'ENBOTTOM DIA.OF WELL E%CAVATI,S#1Y ' ,Mrorrn,,•.tLal Hp,ta=IiI"fiJ�lieLNO_ o <br /> ❑OOMERTICA"VATF. ❑GRAVEL PACK/SITE TYPE OF CASING/STEEL/FVC DIA_Or WELL CAMNO o <br /> ❑PUBLICAAUNICIPAL ❑DRIVEN DEPTH OF GROUT REAL SPECIFICATION S <br /> ❑IRRIGATION/AO ❑OTHER OROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONETOMHO GROUT REAL PUMPED:❑Yr ❑W CONCRETE PED£BTAL BY ORLLER:❑Yw CIN. 5 <br /> APPROX.DEPTH LOCK"CHESTER ROK/STOVE PIPE 5 <br /> moPOSED CONSTRUI;T1ON/ONLUNa METHOD: MUD ROTARY/ AIR ROTARY ADGER CABLE OTHER <br /> II HEVEBY CERTIFY THAT L(LAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH RAN JOAOLRN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> IT OULATONS of THE SAN JOAOUIN COUNTY.ROME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT M THE PEREOROAANCE OF THE WOR,FOR WHICH <br /> THIS PERMIT 19 ISSUED,I BIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRNO OR SURCONTRACTSM MaNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORWIANCE OF THE WOPK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SIIKJfCT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALRORNIA.' TNF APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIR®INSPECTIONS AT 12991 4001 i.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 61—d K T1tl. D.t. N <br /> PLOP RAN Lo..rEN <br /> le <br /> 1.NAMES OP STILEFTG OR LOADS NEAREST TO OR BOU.THE PRO S. LOCATION OF LOUSE SEWAGE DISPOSAL 11TF1.OR PIOPOSED <br /> 2.OITTLINE OF THE PROPERTY,OIM/O D1MfNB10Ni AND NORTH DI IOERPANRION OF SEWAGE pSMeAL SYSTEMS. G <br /> J.DIMENSIONED OUR LINTS AND LOCATION Of ALL EKISi1N0 AHO S.LOCATION OF WELLS wrrmm RAms OF ONE HUNDRED rwTY ET.STRUCTURES,INCLUMNO COVEPED AREAS SUCH ASPATIOS ON THE iTTol'ERTY OR ADJOINING PROPERTY. T <br /> 1 � <br /> i <br /> ' .. ... ... .. c .. PAYMENT <br /> ,pLgIT <br /> . OCT 1 <br /> 5 1998. <br /> SAN <br /> ._. <br /> ' PIJGI.IC HEI HSE <br /> �N✓iR041dIEJfALHL/aLTNp11E.j IOP <br /> f <br /> m=� - <br /> } _ <br /> .................... <br /> noona.Il.n A...pl.d eT <br /> G,M Inr—d—By D.t. RmP Irhveodon DY D.I. <br /> D,.InFv..Irwn�l Br r DIt. <br /> 1 AL:CDt1Nlima ONLY: Nor FAC' �-JI <br /> PE CODES FEF two AMOUNT.—ITHECR MASH RECEIVED BY DATE j PER MITIOFF VICE REDDEST NUMBER INVOICE <br /> 11 0-0 6 <br /> '/C_ Z 13 <br />