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APPLICATION FOR WELL)PUMP FERMI <br /> AN JOAOUIN COUNTY PUBLIC HEALTH SER <br /> F BOX ENVIRONMENTAL HEALTH DIVISION <br /> 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201,W 3�3 <br /> (208) 4663420 <br /> APPLICATION IS HERE By MADE ro rHE sax JogpulN cpuNrvN REFUNDABLE PERMI7 EXPIRES I YEAR FROM DATE ISSUER <br /> JOAQUIN COU FORA fcni M in TTiPlietbl <br /> COUNTY DEVELOPMENT TALE,CH PERMIT R CONSTRUCT AND/OR INSTALL 7HE <br /> AFTER 8-J I S.3 AND THE STANDARDS OF SAN JOAQUIN COU <br /> JOB ADDRESSMA ARNO WORK OE6CRIBED.THIS APPLICATION 16 <br /> COUNTY PVBUC HEALTH SERVICES'EN MADE IN COMPIJ <br /> OWNER'S NA����� /9 C �i ENVIRONMENTAL HEALTH DIVISION.ANCE WITH f <br /> "'-`- 6.e4> P �(.YP #�� -�_CrYl » O(e0 1. <br /> CJD PARCEL APNB 31. <br /> CONTRACTOR T/, � C ADDgESB / �� �� <br /> moo. :27a/�� `sBa9 <br /> SUB COMRACTOq e�Q�yar. ADDRESS PHONE#__:e <br /> 'h/��ADDRF88 236 ZO"TM On. fie-PHONE/5/72 '12021 <br /> TYPE OF WELIJPUMP <br /> ��_ ❑ NEW WELL ❑ REPLACEMENT WELL 26 PHONE I Y <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR MONITORING WELL I Y <br /> —_ ❑Nay❑ 0 CROSS-CONNECT REPAIR El OTHER <br /> RYPE OF vUMPI Repelr H.P. ------ <br /> DEPTH PUMP SEI ❑ VAPOR EXTRACTION WELL It J <br /> OUTOF-SERVICE WELL ❑ FIRST WATER IEVEI�-- <br /> DESTRUCTION: GEOPHYSICAL WELL♦ O <br /> SOIL BORING <br /> INTENDED USE <br /> ❑ INDUSTRIAL TOF YPE <br /> fTp❑p�OPEN BOTTOM CONSTRUCTION SPECIFICATIONS � <br /> DOMEgTO/P NATE LJ GRAVEL PACK/SIZE�' � VPDIA OF WELL EXCAVATION /'C e <br /> DRIVEN <br /> PUBLIC/MUNICIPAL TYPE OF CASINO/STEEVC ��/ / DIA.OF CONDUCTOR CASINO A\ <br /> �—� / ' <br /> ❑ IRRIGATION/AGDEPTH OF GROUT SEAL�. �r/ / GIA.OF WELL CASINO= Q(I <br /> p� ❑OTHER T O <br /> IL MONITORING GROUT SEAL INSTALLED BY —_— SPECIFICATION <br /> APPROX.DEPTH �` 7 <br /> NGROUT SEAL PUMPED: — G/R.OCxUT•BRAND <br /> 5R <br /> PROPOSED CONtTRO ]Yr rycE/ OftNO METHOD: ROTARY LOCKING CHESTER BO%/BTOVE PIPE CONCRETE PEDESTAL BY DRI ER:QYr ❑Ne <br /> AIR TARY <br /> \\ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED TNIB A AUGER —CABLE S <br /> THISREGPERIONSMIT <br /> OF THE BAN JOAQUIN COUNTY, CATION AND 11 I'll WO OTHER <br /> THIS PERMIT IS ISSUED I SHALL NOT EMPLOY NOME OWNER OR LICENSED AGENT'S SIONATURENCERiI IED TroHE FOLLOWING:•1 CERTIFY THAT IN THE PERFOgMANC THE TF WO <br /> PERSONS SUBJECT TO WOgKMAN•t <br /> COMPENSATION IAWg OF CALIFOgNIA.H Co HIRING OR BUBLFINAN RACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING; I CERTIFY THAT IN THE PERFORMANCERDINANCE6,STATE LAWS, <br /> CALIFORNIA.- THF APPLICANT MUST CALL OF THE Wow ANO RULES AND <br /> Pq FOq WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERBUNB SUBJECT R Jili AC COMM On WHICH <br /> NOW IN ADVANCE FOR ALL REQUIRED faism"aR AT <br /> gIY1Mtl% �� // / J 13M1 MtJ/28. COMRETE DMWI PEFltAT10N LAWS OF <br /> Till. / / NO AT(OWER AREA PnoVIDEO. <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE l o—1. ~h P� Data ! lrt ^QS <br /> PLOT PLAN(Dray to eoMsl Bola <br /> OWING <br /> G. DI ENSIONE0 OUTTUNF6 OUTLINE OF THE ANp OCATIjONEOFIALL eEXISTNG AND AND NORTH DIRECTION 4. <br /> Io n F'L <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PgT106,DRI A' LOCATION OF HOUSE SEWAGE DI y,,SYSTEM OR pqp <br /> EXPANSION OF SEWAGE DISPOSAL SYBTFMB. POSED <br /> VEWAYB,ANO <br /> /At" b. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br /> ON THE PROPERTY OR ADJOINING PROPERTY <br /> DEPARTMENT USE ONLY <br /> Application Aacapled By <br /> Grout In —714 Deta Inspection BY O\ L�'T.C.(7 Dete I II I - Arr. l0 <br /> ' Pumv Inep«tlon By >M'Bj\ <br /> Dmrmtlon Imp«lien By <br /> Demmenb: l3• /3-30 /1CCIJ/Z l D.L. <br /> 5 _3 _ 15 z . .. " <br /> ACCOUNTING ONLY: AID# <br /> FACT <br /> PE CODER FEE INFO AMOUNT REMITTED CHECK#/CASH RECpV BY <br /> 290 � � /� DAT P61MIT/Bp1VICE gEOUFAT NUNBEq INVOICE <br /> 9 la S Sle ADO��SS <br />