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J <br /> APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 . <br /> (209) 468-3420 O <br /> NON-REFUNDABLE►ERIK DMWES 1 YEAR FRON GATE ISSUED <br /> MeowisNB in TrirNestsi <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PENAT TO CONSTRUCT AWWR INSTALL THE WOIK DESCRIBED.THIS APPLICATION 16 MADE M COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TTTL2.CHAPTER 9-111S.3 AND THE STANDANDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH 1 N CA <br /> 7067 i 77J L ZZl9 N. LtJLlia�r Y CIT �iacKtD�c/ _� yT+ <br /> Joe AooRE66�oa(n/A�•n+r �j Iy �/�•� !yam �/�� / �y PARCEL 61z�APN� <br /> OWTNERTB NAME [�NU�L ''�+����.""'�+• I�4 ADONEt! l 1.CJ N- ��10� S 11'►�J Ic if f <br /> - <br /> r l/ !,' �,�/ .PHONE <br /> CONTRACTOR ADDPEp�3 "WytN�I�+��41t- —UCS( aa2� PHONE/ <br /> SllS CONTRACTOR <br /> V AD(Me6 6 Afk-Z'� I Q `f. 4s L)C! PHONE <br /> TYPE OFyyEttlPIIIAP: ❑ NEW WELL ❑ REP ACEWNT WELL ❑ Mo.wrowNo WELL I ❑ OTHER <br /> ❑ wwALLATION ❑ WELL erarEm RerAII ❑ CRIOst•COW*CT REPAIR ❑ VAPOR EXTRACTION WELL I •� <br /> ❑N...❑ HJ'. DEPTH PUMP SET FT. �FIRRST WATER LEVEL O <br /> (TYPE OF PUMP1 IY❑ sOs.sOaIN'0 �_ 6 OVT-0F sE71VICE WELL ❑ OEORfY61CAL WELL I TT <br /> ❑DESTAUCTIow. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSw �� A <br /> ❑ INDUSTRIAL ❑oPEH soTTOM DIA.OF WELL EXCAVATION A,jI�J pA_OF CONDUCTOR CASINO Q D <br /> R <br /> ❑ DOMESTICAVATE ❑GRAVEL PAC%Mn EEUPV <br /> TYPE OF CASINO/STC - DIA.OF WELL CASINO D <br /> ❑ PUeLLCAMUHICIPAL -�RDIOVEN DEPTH OF GROUT SEAL S-A / sPEC1FlCAT10N R <br /> ❑-/sY110ATlON/AO ❑OTHERGROUT SEAL INSTALLED BY GROUT BRAND NAME O � E <br /> mid Mo►wTOWNo GROUT SEAL PUMPED. ❑Y-004. //�, CONCRETE PEDESTAL SY DRILLER❑Y- ❑N. s <br /> s /15' <br /> s ' Loc"m CHESTER eOX/STOVE PIPE/!�T S <br /> APPROX.DEPTH <br /> PROPOSED C011STRUCTIONIVWA M METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE.WaY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL M DONE N ACCORDANCE WITH SAN JOAMM COUNTY ORONANCES.STATE LAWS.AND RULES AND <br /> RIEOVLATpNB OF THE SAN JOAOUN COUNTY. HOME 0"1"OR UCfHtED ADEM-2 SI GNATUIE CERTIFIES THE FOLLOWING:'I CERTIFY THAT N THE PEfIFORMANCE OF THE WORK FOR WHICH <br /> THIN PEFSATT IS ISSUED.1 SMALL NOT EMPLOY PERS"SULSECT TO WOIOOAAWS COMPOMATON LAWS OF CAUFOINIA.' CONTRACTOR'S HIRING OR SUS-CONT ACTNO BIGNATVRE CERT <br /> THIN <br /> THE FOLLOWING: CERTIFY THAT N THE PE��Houmwj <br /> THE WORK FOR WHICH TMS PESMR K ISSUED.I SNALL EMPLOY PERSONS SUI IECT TO WORK MAN'S COMPEIMATION LAWS OF <br /> CALIF0IMA.' 24AN"POR ALL REOLIRtiD INMSCT^TIRONS AT(200 400-3422. COMPLETE DRAWING AT LOWER:71*- <br /> TSMle' <br /> }MOT FU1N D.ew M SWIM Sed. M <br /> MES OF NTREETe OR ROADS NEAREST TOOR BOOMING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROI'OBED <br /> I. NA <br /> 2. OUTLINE OF THE PROPERTY.OIVIIO DISAEi�NS100�,^'NOMI DIFECTIONR• EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> ]. DIMENSIONED OUTLINES AND LOCATION OF ALL ONN <br /> OSTO APO PROPOSED S. LOCATION OF WELLS WRIIRRN RAW"OF ONE HUNDRED FIFTY Ff. <br /> STRUCTURES.INCUMMM COVERED AREAS SUCH AS PATHOS.DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOIO/G PROPERTY. <br /> .. ....... _ <br /> .... ...... .. .lr ... - _ ._ <br /> : <br /> . <br /> DEPARTMENT IISS ONLY <br /> AIPM~A-.Pt.d er <br /> O.wA Ir»...IM,.er D.a Pt.nP bw..IMn Sr ON. <br /> Dd. <br /> oedn,elM'. <br /> k-.00-By <br /> ACCOUNTING ONLY: MGI FAC/ <br /> PE CODES FEE INFO AMOUNT"OMITTED CRREDXIICASH RECEIVED NY DATE POSHITISEIVICE REOUESNUMNV <br /> T BER INVOICE <br /> D -.-- I q Z <br />