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APPLICATION FOR WELLIPUMP FERMI( <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> RO. BOX 388,804 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 46113420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED <br /> (Complete in T/IpRe6te) <br /> APPLICATION Ie HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE MH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOA UIN COUNTY B�PjI LIC NFBLLTA SER ICES,E NI{IONMEq'rEALTN DMBION, <br /> JOB ADDRESSMA ANE wuiib D^�1 - _J�_ Ll (Iv- OVT'•fOwO�•__ t�`y YL /�If-rbc r.7J 82EIAPNF �J -J <br /> OVMER'8 NAME re 3 R V-DIWREe RIONE v7x <br /> CONTRACTOR AOOREBeI LIC/ PHONEA-'+J�,hI�LJf"Z�- <br /> SUB CONTRACTOR ADORER .LrJ.T�..�(/��) <br /> TYPE OF WELVPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL XMOMTORNG WELL FAr ! ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> ❑Nen❑Sev.I, ".P. DEPTH NMP SET_". FIRST WATER LEVEL O <br /> (TYPE OF MMPI <br /> ❑ out AFBFRVOE WELL ❑ GEORIY6ICAL WELL• BOIL 80RING P <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> (I <br /> ❑ INDUSTRIAL ❑OPEN BOROM DIA.OFN/ELL EXCAVATION DU.OFCONDUCTOR CASING O <br /> ❑ DOMESTRCMRIVATE 11)p�RAVEL PACKIBIZE TYPE OF CASINOISTEEINVC DIA.OF WELL CASH 'y O <br /> ❑ NBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL = 6PLCIFICATION f S <br /> ❑ ISNOATIONDAG ❑OTHER BMW SEAL INSTALLED I r 4.L GROUT BRAND NAME I E <br /> �MONITORINO GROUT BEAL NMPED! Y. <br /> Ne C NCRETE PEDIE-ST'AL""LL Vs ❑N. 5 <br /> APPROX.DEPTI VDL'-4 L7)�11:J wO�T"�CIJ! LOCKING CHESTER BOX/STOVE RPE I (J� PQM S <br /> PROPOSED CONSTAVCTIONRNBWNO JMETMD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER <br /> 1 HEREBY CERTIFY THAT 11LAVE PREPAREO THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REO SAN JOAOUIN COVNTV. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE FERTORMANCE OF THE WOR(FOR WHICH <br /> T PERMIT IS ISSUE I BIIALL NOT EMPLOY PERSONS SUBJECT TO WBRKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR MR CONTRACTING SIGNATURE CERTIFIES <br /> T E FOLLOWING: •1 C RTIFY THAT I!THE FERVOR ANCE O„ HE WONT(FOR WHICH THIS PERMIT IB ISGUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CA RNIA.- THE AP QANT MUSIC 2411 8I ANCE FOR ALL REOMRED INSSPE/FCITIOONE`AAT 1206148241432. COMPLETE DSAWNG AT LOWER AMA PROVIDED. / <br /> SI0rn0 X Thl. /�[ Y 1 s D.I. /Z-- q �1..I! <br /> T <br /> PLOT PLAN 10ren to Se .1 Gale 'I. <br /> 1. NAMES OF STREETS OR ROADS HE TO OR SOUNDING THE PROPESTY. 4. LOCATION OF HOUSE BEWAGE DISPOSAL SYSTEM on Pr10P06ED <br /> 2. DATUM OF THE PROFESTY.GIVIN IMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLB WAAMN RADIUS OF ONE NUNDMO FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE ROPERTY OR ADJOINING RKIPLRTY. <br /> wtu- <br /> 1 I <br /> wlw 26 Ia p Sal k 66wR6( <br /> Yv1iJ ��o o (Moe - U u <br /> ...................... li <br /> OTDMTMFNT USE ONLY <br /> ApplN.lbn Aeeeptal BY ,`'•FWT�)I tY•`L`A('IIF//ALr L O.0/� /�� Aru <br /> N.0 Inveellen Br DHe wnv Inveetlen BY DH. <br /> Onlnctlan Invxllon BY O.te <br /> Cemmax.: <br /> ACCOUNTING ONLY: RADE <br /> PE CODEC FEE INFO AMOUNTADMIITTTED CHECKOMASH RECEIVED BY DATE PEMIITUFAVICE REBUEST NUMBER <br /> -/: INVOICE <br /> 1 OW45 <br /> D <br /> Pub.Health Sam.-Enviro.173(3196) <br />