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APPLICATION FOR WELLJPUMP Pr T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH _ _AVICES <br /> �� ENVIRONMENTAL HEALTH DIVISION <br /> / I I '} EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)46e-3420 _ 39'71-U I <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> IComploll In TIIpIksI@I <br /> AIY•IICAT ION IR HERE BY MADE TO 711E BAN JOAGUIN COUNTY fon A 1•CnM1I 10 CONSTRUCT ANDIOn INC I ALL 711E WORN DESCIBBED.THIS APPLICATION"AGE IN COMPLIANCE VYfl11 BAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE..C�IIAPTER 9-1115.3 AND TIIE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC STEALTH SERVICES,EIMRONMENTAL HEALTH DIVISION. <br /> JOB AODnESSIOn APF/ T• I CITY PAncEL BRE/APN/ <br /> IILA'L I <br /> ADDRESS <br /> OWNER'S NAME- 1 RIONEI�-3R�yf-y,+g-' 33 <br /> ADORE BB 5(:. r UC/ PHONE I V LL] <br /> CONT MCTOR �r7 �Ll LZ <br /> BUS CONTRACTOR S lil 1!A ADDnEBB l/ �/` �/'>/S UCo 51 — PHONE <br /> WELL/ ❑OTHER ' <br /> TYPE OF WFII/PUM►: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WE ❑VAPOR E%TMCTION WELL/ <br /> ❑ <br /> INSTALLATION El WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR O <br /> (TYPE13 _ 1 <br /> DEPTH PUMP SET�FT. FIRST WATER LEVEL /+ /��'.�y, <br /> ❑N«v 13 Repelr H.P. ma���pyFF,,,, � [•�0 1 1 <br /> (TYPE OF PUMPS �SOR BONNO �I l/ B <br /> OVT�OF-SERVICE WEL OEOAIV 6ICAL WELL❑ I \ \ <br /> DESTRUCTION: rI <br /> INI[NU ITPE OF WELL CONiIR / <br /> TION SPECIFICATION <br /> CI <br /> Uif GIA.OF CONUVCTOR, <br /> R <br /> CASINO <br /> ❑INIlUR7NAl ❑OPEN SO7TOM DIA.OF WELL EXCAVATION <br /> DIA.OF WELL CASINO 0 <br /> Ivlr Or cnmF+Olntrnn•vr. ! <br /> El 1,D., <br /> ONCBnUVIAIF. ❑OMVFL PACXISVF SPECIFICATION R <br /> DEI'TII OF DROVT 6CAl <br /> ❑TvnLICMuenclrnL ❑ODIVEN oROUT BRAND NAME E <br /> ❑Inn1OAISONIA0 ❑OTIIEn OnOUT SEAL INSTALLED SY <br /> OnOUT SEAL PUMPED:❑Yr ❑Ne CONCRETE PEDEBTAL eY DRILLER:❑Vee ON. S <br /> ❑MONITONNO S <br /> LOCKING CHESTER SO%IBTOVE APf <br /> APrROX.DEPTH CABLE OTHER <br /> mOroSED CONSiRUC TIONIdSWMO ME7110 D: MUD ROTARY <br /> AM nOTARV AUGIR <br /> ONC IN <br /> AGUIH <br /> INA"CES, TATE <br /> nFDlll Al IOI RI DF TIME RANI JDAOU N COUNTY-110ME OAWNEn On L+Cf NSrn AWOW <br /> N�B e,n.Al Unf CFRIIFHR TIME IOL OWING:t CERTIFY THAT IN THEPERFORMANCEOF il!Wow Ton wi ITCH <br /> 7 NIR rFRMIT M IRRVFD,1 OIIAII NOT EMPLOY A'OnONB SUBJECT TO WORXMAI+'f COMrEN.ATION LAWS Of CALIFORNIA.-CONE PERSONS TURING OTO WO OH AH'It NO SIGNATURE CERTVICR <br /> 711E FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF T/IE Won%Ton WHICH THIS TERMIT IB IBSUED.I SI/ALL IMF <br /> PERSONS SUBJECT TO WORIOAAN'S COMPENSATION UWB Of <br /> vAPP11tA9STvALL1 HOURS IN ADVANCE FOR ALL REOUR�EO 11�ySI ;NS AT ITSI 4410.3423.hSf,C►OMPLETE DRAWING AT LOWER AREA PROVIDED.J.CAUFOnN1A.• NUFS <br /> Thle DOW <br /> Blend X PLOT <br /> PAN 1D.µIo Sed.l P-1-- Ie <br /> �.LOCATION Of IgUSE SEWAGE dBroIAL SYSTEM OR rnOro GED <br /> 1.NAME"Or BTnErl a OR MAGICNFAIIE ST 70 On BOUNDING 711E PIIOI•FnTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> },OUTLINE OF 711E RIORREY.OIVINO DIMENSIONS AND NORTH DInECTIOH. S,LOCATION OF WELLS Wr"RN RADIUS OF ONE HUNDRED FIFTY rT. <br /> 7.DIMENSIONED OVTLINFII AND LOCATION OF ALL EXIITINO AND PROPOSED ON THE PROPERTY On ADJOINING PROPERTY• <br /> a,RUCTUREe,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. <br /> 4.... <br /> ' 11TUE1 15:19 ROLTE LAl—, 1ALIU ml <br /> _I/ - <br /> .. <br /> lomrnn a ��(t <br /> Mal. <br /> 4-4 <br /> ua <br /> i . <br /> ®1 f . L <br /> OLL.Nw.~1 _ {... <br /> • RAt 1 ..,.. ,let <br /> -3 �1 0 <br /> 1 <br /> � • <br /> �9I <br /> - - Bllal <br /> 1 <br /> AbdN.tntiol ........ <br /> uW <br /> i Bu1761oq ���Y Mb J� l/����j���Qp,�R•�.J t�, <br /> r....... <br /> 5 n ylYL,r' q <br /> s <br /> DEPARTMENT USE ONLY / <br /> Di1S � N/M�B�B <br /> Appfl M1 en A..-Id BE <br /> D.I. Pvnr Insp"len BT <br /> B.eW Inrreellen BE �{ <br /> D.»mranen In.ree"on <br /> By <br /> cemmNR.: <br /> ACCOVNTINO ONLY: <br /> NDI FAC! <br /> PE CODES FEEINFO AMOUNT REMITTED CIIECKIIC ASIS RECEIVED SY DATE <br /> ►E MITISFRNCE REQUEST NUMBER INVOICE <br /> 37�L sc12 Jl► `�'— ' <br /> Pub.Health Sam•Enviro.173(1/97) N / 7 <br /> � � <br />