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APPLICATION FOR WELUPUMP PERMIT <br />SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P,O, BOX 9881 %4 EAST WEBER AVENUE, STOCKTON, CA 91J2a1 ggg <br />1209) 469.3420 <br />D"EFtlIDASLE ERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />fCDmp1ELE In TrIpIlest"SI <br />APLCAYIITN R HERE By MAO! TO TIIE GAN JOADUIN coHriry FOR A PERFAIY TO CONSTRUCT AND/OR INSTALL THE WORK bESCRIBf.D. THIS APUCATION 10 MADE IN COMPLIANCE WHIN SAN <br />JOAOUIN COUNTY DEVELOPME/W%THI.E, CHAPTER <br />/R/-1111 /6.3 AND 711F STANDARDS OF BAN JUAOVN COUNTY PURL 1C IREALTN 9ff1VICEe, ENNPxINM[NTAL IIFALTH pLIBION. <br />JOB ADD/IESSRq NRI/ , 17 %I LJ!>.7"l /L.I� i'.�/� <br />PARCEL ORF/APN/ i1 3 <br />OVA"'B NAME Ji)_._ADUREee�{j l�' J 7 ] ,7 PHONE/ <br />CONI MCTgI_� ' ^ mIDqF.RB____ UCI <br />PHONE <br />PUS CO W RACTOfl <br />AbbOEIb� �_ UCf^W,__ <br />�-y PHONE � L1�` <br />TY. Fk OP WMP;ELLAVIJ NEW WEU. r� RFPLIrfMFNT w(".IQ-� MONITORINW,I <br />G ELL C� OTNEq__ '"1` `4 <br />El INSTALLATION Q WFRL JYSTEM REPAIR LJ CROSS -r ONNECt RFPAIN ❑ VAPOR E%TMumn WELL / <br />_ ❑ Nwv d r-1, FI. P. DEPTH PUMP tk T�_i'. FIST WATfR LEVEL <br />Ryi'E Or PWAPI �/f�J/J j_I,/� F --I _ p <br />Open 1>1 f7L1C E' OUT On-BFRVICE WELL 4J OEORWGICAMWFLL I <br />LJ — n <br />1NOVOTRAl. .HIEN BOTTOM VIA. OF WELL F%CAVATION__ _ SIA. OP CONDUCTOR CABINS <br />ry n <br />LJ DOMESTICMC AL Q OMEN PACKlBUE <br />TYPE OF CAMNOIC TEEI M— _ b1 A. OF WELL CABINS D <br />❑ PNN.ICIMIIMCMM ❑ OMEN DEITH OF <br />O110u1 BF.AL BIECIFICATION A <br />❑ BRRIOATIONIAO Q Di HER ----- <br />OR011f BFM INSiIIL1ED BY GROUT BRAND NAME <br />11 "MOTORING <br />�.l <br />� OROU7 BFAL PIMPED: ❑Ye. QN• CONCRETE PFOESTAI. BY DRILEp: ❑ Vw ❑N• S <br />APPIox. DEITN---C!Le�llJ 111 LOCKING CHFOTEn Boxm70VE P"(� <br />P110PoEFD CONETflIICTNf NO <br />METHOD: MUD ROTARY AIR ROTARY AVCER—_._- CABLE <br />OTREF <br />1 •iE4FBY ClRfIFY THAT I HAVE PREPARED THM APPLICATION AND THAT III( WOR( WILL BE DON E N ACCORDANCE WITH BAN JOAOInN <br />REGULATIONS OF TI /E RAN JoAOURP COUNTY, COl1NTY ORpNAtLCFO. 6TATE LAWS, ANO RULES ANO <br />HOME OWNER OR LICITISED AGFW'B 810NATUnE CERTIFIES THE PULLONMo, 'l CERTIFY THAT <br />THIS <br />IN TIIE rEIIFORMANCE OF THE K FOR WMCH <br />PERMIT b ISSUED, 1 MIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPMEATION LAWS OF CALIFORNIA.' CONTMCTOq'B <br />HIRNO OB SUR-CONIRAC7IN0 OIONATURE CERTIF"IE"S <br />Tf/E FOLLOWING! • 1 CEnt" THAT IN THE PERFORMANCE OF THE WORK FOR VAfICII TITIN rFnMIT IS MSVEb, 1 SHALL EMPLOY PERSONS SUBJECT <br />CAUFORNI ' <br />COMPCOMI <br />EN"SARON IAWb OF <br />TNR A M LL II NOUM N AOVANC% FOR ALL REQUIRED INEFBCtPONe AT 1] 4@94471, COMPTO WOTtlp.IAN'S LEtE OMWINO AT LTO W AREA 1'R <br />_ <br />BIBII•e x r} <br />`, <br />TIBe / J "/Y / G % <br />_... N Sha.. 1• "SoN.l Seel• • 1• <br />1, NAMES OF STRlETO S NEARER? TO OR BOINUNBI PROPERTY. <br />OUgE S <br />4. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM ON P1bPOeEb <br />7, OUTLIM OF THE P OPERty, OMNO MAFNWDN"S AND "OMIT DNUCTIOIr. <br />E%FATTIO N OF DISPOSAL SYSTEMS. <br />3. =F"SK*ko OUTIJNrS AND LOCATION OF ALL E%ISTINO AND PROPOOEO "S- IOrAilnu nc u,el,A E tha ......... __ __.-._..-- _. <br />hnMloollon A.e•FI•A p, <br />Grow IIwPAetlon BY__-_ <br />noM„ka�, In•P••nm, n <br />ACCOUNT NO ONty: I ND/ <br />TIE Cobra I FEE INFO I AMOUNT MMITTBD <br />/3"x.3 1/nlwJ �! l/1H <br />Pub, HflBAh SDN. - Envila. 173 (3/96) <br />US! ONLY <br />race <br />CHECKOXASH I RECEIVED BY I DATE <br />Z39 T I,6 w <br />bN.�—C � r Are•,_—.__,_-__. <br />ON•_ <br />F6W1ItISfTMCE REQUEST NOMB91 <br />INVOICE <br />