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ti , t APPLICATION FOR WEL PUMP PERMIT <br /> M i 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES REr <br /> ENVIRONMENTAL HEAL TH DIVISION <br /> 304 EAST WEBER AVENUE MAY <br /> 5 CKTON, CA 95202 2 G 1998 <br /> (209)468-34 0 ENVIRONMENTAL HEALTH <br /> NON-REFUNDABLE PERMIT WIRES 1 TFAR FROM DATE ISSUED PERMIT�SERVICES <br /> mampiiti In Trip til <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WORK DESCRIBED.TIRS APPLICATION IS MADE IN COMPLIANCE WfrH BAN <br /> JOAOUIN COUNTY DEVELOPMENT TrTLE,CHAPTER 9-1116.3. T E STANDARDS OF SAN JOAQUIN IOUNTY PUBLIC HEA T SERVICES, NVIRONMENTAL HEALTH DIVISION. <br /> JOB AOORESS/OR APNI CITY PARCEL SI;F/APNI <br /> OWNER'S NAME ADORERS .7 la ,�//V PHONE/ `v <br /> COMPACTOR ADOREas LIC/ PHONE I <br /> SUB CONTRACTOR ADOMBS LICK PHONE f <br /> TYPE OF WELL1PUMf9 ❑ NEW WELL ❑ REPLACEMENT WELL 0-po rtO1VNG WELL I 4 ❑ OTHER <br /> Q INSTALLATION DWELL SYSTEM REPAIR j ❑ CROSS-CONNECr REPAIR ❑ VAPOR EXTRACTION WELL I J r <br /> ❑New❑Rep* H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O <br /> {TYPE 4F R1MP1 ' <br /> ❑ OUT-0F•SERVIC£WELL ❑ GEOPHYSICAL VIELL I ❑ BOIL BORING B <br /> ❑DESTRUCTION: ry ' <br /> f <br /> INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATION i' .A <br /> ❑ INDUSTRIAL ❑��'=pT'Tc0:""i'_ <br /> y VIA.OF WELL EXCAVATION O DIA.OF CONOUCTOR CASINO O <br /> ❑ DOMESTICI RIVATE 1}StTYPE OF CASINO/STEEL/PVC Ztr VIA.OF WELL CASIM[i 2, .-. b <br /> ❑ PU8UC/MUHICIPAL DRIVEN DEPTH Of GROUT BEAL' "" SPECIFICATION q. <br /> ❑,IRRIOATONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E I <br /> MONITORING GROUT BEAL PUMPED: ❑Yea 1114. CONCRETE PEDESTAL BY GRILLER:❑Yr ❑Ne S <br /> APPROX.DEPTH 75 LOCKING CHESTER I QXlBTOVE PIPE � S <br /> PROPOSED CONfT RUe'nONR)IBLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HM9Y CERTIFY THAT 1 HAVE REO THIS APPLICATION AND THAT THE WOW WILL BE DONE II'1 COROANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO ;+ <br /> REGULATIONS OF THE SAN OUYW"TyME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH <br /> THIS PERMIT 181 SSf LL NONS SIJBJEC7 TO WORWAAN'S COMPEN ATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIESTHE fOLLOWI EPT THARMANCE OF THE WORK FOR WMICH THIS PERMIT IS 1 SVEO,1 BNALL EMPLOY PERSONS SUBJECT TO WOPWNAN'S COMPFNSATIGN LAWS OF <br /> CALIFORNIA.' APPR7 NT MUURS IM ADVANCE FON ALL f1EOU1RE) i TIONS AT ItDS1 ip�42i. COMPLETE DRAWING AT LOWER AREA PRO <br /> 84.0d X Tltla' <br /> PLOT PLAN BAaw to Santa)Beal. 'to <br /> 1. NAMES OF STREETS OR ROADS NEA BT TO OR ROUNDING THE PROPERTY.. I♦. LOCATION OF HOUSE SEWAOE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.OIVIMO DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE bISPOSAL SYSTEMS. ' <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOEEO i. LOCATION OF WELLS WRTMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> BTRLICTLRiES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIXS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> a <br /> DEPARTMENT USE ONLY 7 <br /> Applleatlen Aeeepted BY - - ••• - ^• - - Data S Z` u At" J <br /> Oteut Impmtbn BY Date Pump Ineveetlen @I ^Dole <br /> D—t—don Inspection BY Date <br /> ACCOUNTINO ONLY: AID/ FACT a <br /> PE CODES FEE INFO AMOUNT REMITTED CgqHECQIU+�ICASN REGEVED BY b 7E PERMITMEHVICE REQUEST NUMBER 'INVOICE <br /> 352 <br /> ¢$3 Z t„ <br />