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1i <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL.HEALTH DIVISION <br /> f 304 EAST WEBER AVENUE, STOCKTQN, CA 95202 F <br /> (209) 458-3420 <br /> NOW-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM IDATE ISSUED, <br /> IC3lnpkb hI?rlglfesnl 1 � i <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE#WORK DESCRIBED.TINS APPLICATION fS MADE IN COMPLIANCE WRIT SAH <br /> JOAOVIHCOUNTY DEVELOPMENT TITLE.CHAPTER 8-11115.3 AND THE STANDAROB OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH OMBIDH. <br /> JOB ADCRESSlOR APN/ b O I�D1'4At GQ t CRY Loc}L 1, PARCEL sIZElAPN.�.�O <br /> a // j 1�,y," } f - } 7�( <br /> OWNER'sNAMEG-'Wf •+ V3j0 a 1-'F�P ��, ADDRESS _0' o i_ZIoiwd„iPIIM.'3/T '0366 <br /> CONTRACTOR Ott F11 V 1 1-0 4 At 4q 14Cf I'1 - ADOFiEBe`{00'; hjjjwi LrIQ;I ky't”" IICI Q!'� PHONE R —10{f <br /> SUB CONTRACTOR ADOPiEB6 <br /> AJC/ PHONE. <br /> `F <br /> TYPE OF WO JMMP ❑ NEw WELL ❑ REPLACEMENT WELL ❑ MowrOmNO WELL. © OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR !r ❑ VAPOR exTRACTpN WELL/ <br /> ❑w.❑Rap h H.P. DEPTH PUMP SET FT. ' FIRST WATER LEVEL O <br /> FTYPE OF PUMP <br /> ❑ OUT4F•SERVPGE WELL © GEOPHYSICAL WELL f cps SOIL SORINGy� � <br /> S <br /> ❑DESTRUCTION- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SEFORCAT10NS +7 Nr ii A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONf OfA.OF CONDVCTOR CASINO D <br /> ❑ DORIESTICMMVATE ❑GRAVEL PACKINZE TYPE OF:CASINOISTEEL/1"VC'7� � SII DIA.OF WELL CASNIO " p <br /> ❑ P191JCJMUNICWAL I/aDRTVEN DEPTH OF GROUT SEAL 1 — it SPECIFICATION q <br /> ❑ ERRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY Tr4ml L 140 GROUT BRAND NAME POtf l(lR C111L�q � E <br /> It MONITORINGL_ r GROUT SEAL PUMPED: ❑Yr IAN. ''k CONCRETE PEDESTAL BY DRILLER❑Y« ®Ne S <br /> APPMX.D.'" 7 LOCKMO CHESTER BOxmOVE PIPE- <br /> PROPOSED <br /> S <br /> PROPOSED CONSTRUCTIONMINUM0 METHOD: MUD ROTARY AIR ROTARY AUGER 1 CABLE OTHER QT t c LL S <br /> 1� <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED TMS APPICATMN AND THAT THE WORK WILL BE DONE M ACCORDANCE Y fM SAN JOADUIN COUNTY ORDWANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUSN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOW M'•I CERTIFY THAT IIN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSON!!SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFDFOIIA.- CONTRACTOR'S HIRING OR SUBCONTRACTINO SIGNATURE CERTIFIES <br />` THE FOLLOWING; -I CERTIFY THAT W TIE PERFORMANCE OF THE WORK FOR WHICH TMS PEWMTT IB ISSUED.1 SHAD EMPLOY PERSONS SUBJECT TO WORIOMAW0 COMPENSATION LAWS Of <br /> f CAUFORMA.- THE APP/NC�ANT�MUST CAUL 24 HOURS IN AUVANCIE FOR ALL MOIBRM iN&MT1ONS AT F20ST 44l-3422. COMPLETE DPAWM AT LOWER AREAfPROVVIDED. <br /> [� <br /> sfpned X rl is !7/'ic•�1 /11^�'S - — TINT 5;sn� �.rrf 6"'C io;'�t.� T Dal. 6�/f.g� L <br /> PLOT FUN ID�.w to Seral Sofa <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.OPANO OIMENSIONS AND NORTH!DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DWEN9KYWO OUTLINES AND LOCATION OF ALL EXISTMG AND PROPOSED f. LOCATION OF WELLS WITHIN MOMS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERIM AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON tK:PIOPERTY OR ADJUM M PROPERTY. <br /> it <br /> OVARTMENT USE ONLY <br /> AppNpetion Aaamted my !^ D.. Nr &00 Up <br /> G.wt InapaeNen By Dna Puna It from By DNa <br /> Daatnmlwn In v-le.13 ;s Dale .. . <br /> Cemmarxr. S �� . <br /> i� <br /> ACCOUNTING ONLY' ANL. FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHEGACASH REC9VED BY DATE j1 PH74MITJSEIMCE 1190UUT N1IANER INVOICE <br /> ',6 <br />