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APPLICATION FOR INELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC0 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKMN, CA 95201388 <br /> (209( 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM RATE ISSUED <br /> (Complete IR Triplicate) <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR!DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WTI11 RAN <br /> JOAQUIN COUNTY DEVELOO MEENT Tal.CHAPTER 9-11116.3 AND <br /> THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES•ENVIRONMENTAL HEALTH DIVISION. F O <br /> JOB ADDRE83roR A/Pn•NI CiG/ (�✓7{R (,L '/�,�E S' CIT( ��CjIC1,�/� PARCEL SI2E/APN/ �J2—D7D— �J <br /> OWNER'S NAME l�� ©l��l'�S10G K.�� ADDRESS 1.�/ CG MIONE 14 -7- 9-711 <br /> � <br /> CONTRACTOR J� i1 ADDRESSd� LICI s�nbg IYIONE/- ��S RL�� <br /> BUB CONTRACTOR ADDRESS IJC/ PHONE 0- <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ DEPLACENENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> 0N.0 SeedSE <br /> r H.P. DEPTH PUMP T M FIRST WATER LEVE( p <br /> RVR OF PUMP) <br /> 11 •OUT-or-SERVICE WELL 11ry'GEOPHYSICAL WELL S p(J 6011.BORING �/ �/ G( a-1 B <br /> 11 DESTRUCTION- <br /> - <br /> •` �{Te>y �AD'1 /"r., <br /> INIENOED USE TTPE OF WELL COHfTRUCIION#PECIFICAl10Hf /� A <br /> ❑ INDUSTRIAL ❑OPENBOTTOM DIA.OF WELL EXCAVATION DIA.OFCONDMTORCAStNG D <br /> ❑ DOMEBTM/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/6TEETU'VC DIA.OF WELL CASINO O <br /> ❑ PJ6lICIMUNICIPAL ❑DRIVEN DEPTH OF SHOW SEAL e{ECIFICATION R <br /> ❑ IPRIOATON/AO 11 OTHER GIROVT SEAL INSTALLED BY GROW BRAND NAME <br /> ❑ MONITORING , per/ GROUT SEAL PuMPSOT ❑Y. [IN. CONCRETEPEpEBTALBYDRILLER:❑Y. [IN. 5 <br /> APPROX.DEPTH ,ZS l /fey LOCKING CHESTER BOXMOVE PPE S <br /> PROPOSED CONeTRUCTIONGMILUNO MUMS: MUD ROTARY AIR ROTARY AUGER V CABLE OTHER <br /> I HERESY CERTIFY THAT I HAVE PBEPAREO THIS APPLICATION AND THAT THE WORC Wlll BE DONE 1N ACCORDANCE WITH SAN JOAOVIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." COMPACTOR'S HIRING OR BUB-CONTMCTING SIGNATURE cus-nnES <br /> THE FOLLOWRIG: RFV THAT IN ORMANCE OF THE FJOIR FOB WHICH THIS PERMIT IB ISSUED•I @HALL EMPLOY PERSONS SUBJECT TO WORKMAN'#COMPENSATION LAWS OF <br /> CAUFOPNIA." T/ APP CANT MUfT RFI. MEOW#IN OVANC OhALLR NfpEC1i,xe 1313! COMPLETEOM OgEA E� <br /> ROT N ID,.IP#Petal%.I. "to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO 0UNMNO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOBAL SYSTEM on PROPOSED <br /> I. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM@. <br /> 3. DIMENSONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED a. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PIOPERTV OR ADJOINING PROPERTY. <br /> -- <br /> IS <br /> witiN <br /> 1 N <br /> o ti. <br /> 3 c a <br /> PL U <br /> - s amuA n'Ln' <br /> M M, dy <br /> — o 0 <br /> 7(/( Ar yarn ppi <br /> Ir l <br /> I <br /> J � O <br /> a <br /> o0z <br /> hl <br /> i <br /> kid <br /> i <br /> OVMTMU/T USE ONLY <br /> AppllPglen APPgr1eA BY Dele Au <br /> 0'.`A lMPePllen BY < Oete R Plnepeellen BY f Del. <br /> OP.n.,:uen In.PePBen eY_ S �RI ri trh S'�� 1 `1' <br /> Date <br /> Cemmwne: <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE INFO MOUNT REMITTED /CASH RECEIVED BY DATE PERMITJADIVICE REQUEST NUMBER INVOICE <br /> 2 - os <br /> Pub.Heetth Sew.-Enviro.173(3/96) <br />