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APPLICATION FOR WELLIPUMP PERMIT <br /> S AQUIN COUNTY PUBLIC HEALTH SERVICES • <br /> P-0- BOXENVIRONMENTAL HEALTH DIVISION <br /> 38B 304 EAST WEBER AVENUE, STOOKTON, CA 95201388 / <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ` <br /> PLICATION I6 HERE BY MADE TO THE SAN JOAGOW COUNTY FORA (CtmpMn IR Triplietbl <br /> OAOUIN COUNTY DEVELOPMENT TRLE,CHAPTER 8-1115.3 AND THE STANDARDS <br /> TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS A <br /> OB STANDARDS OF SM JOAQUIN COUNTY PPLICATON 16 MADE IN COMPJANCE <br /> DRESSI APNI / PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. WITH SAN <br /> �/•C/la,/4 ura to/6/_//63-1720 1J) <br /> WNER'S NAME Gni/�[/9 //v1'/1 ��cRv d`' , E / <br /> !/ PARCEL SOEIAM,,! 02DC -% <br /> ADDRESS /-;O- n <br /> ANTRAC70R / e <br /> � �L -(',�A �0 :57-g <br /> !'-h <br /> PHONE Y, / 76 <br /> :UB CONTRACTOR ADDRESS?70/r yolr!- / $'./(.. —E •8 <br /> 7/ // � �•�� �I—PHONE I Y7 -2JJj,� <br /> ADDRESS 2,�S 1./! •-W-_Js /)/' e2 2 G <br /> `PE OF LIC# J 9 <br /> O NEW WELL PHONE#SL`71j <br /> REPLACEMENT WELL MONROPNG WELL# <br /> O INSTALLATION O WELL S UEM REPAIR O OTHER <br /> 11 CRDS"ONNECT REPAIR <br /> IR-OF NaW❑RapNr N.P. <br /> PIMP DEPTH PUMP VAPOR EXTRACTION <br /> WELL# � <br /> EJOVT.OFBERVICE WELL SET—Fr. 13 FIRST WATER LEVEL . <br /> 7 <br /> DESTRUCTION- � GEOPHYSICAL WELL I O <br /> ,Cy SOIL BOWNO y <br /> 'TENDER UtE (( ' B 'L�J�Vx(- <br /> TYPE Of WELL <br /> ❑ <br /> J INDUSTRIAL OPEN BOTTOM CONSTRUCTION SPECIFICATIONt <br /> DOMESTIC/gyyATE 19 DIA,OF WELL EXCAVATION fn0 <br /> '•-'OMVEL PACK/8REf llnd TYPE OF CASINGMEEUPVC /VC— DIA.OF CONDUCTOR CASING A <br /> PUBLK:/MUNICIPAL O DRIVEN �— O <br /> J <br /> IR ❑OTHER %0 <br /> RIGATION/ DEPTH OF GROUT SEAL 42' SPECIFICATION <br /> SPECIFICATION O <br /> GROUT SEAL INSVIA.OF WELL CASING=— �^ <br /> MONRORING INSTALLED BY FJ//,�f - [�\d <br /> GROUT BRAND NAME R �J <br /> "OX.DEPTH �7 y yC GIOUT SEAL PIMPED: JRY. ❑No �^1 <br /> NOPOSED CONSTRUCTION/OmWNO METHOD: MUD ROTARY LOCKING CHESTER SO%KRONE PPE /-/U I/CONCRETE�O,, PEDESTAL BY pryl1ER:O Ya ❑Ne E <br /> S <br /> AIR ROTARY AUGER <br /> IEREBY CERTIFY THAT i NAVE CABLE S <br /> PIIEPAR U THIS APPLICATON AND THAT 7HE WOW WILL ��OTHER <br /> -ODUTIONS OF THE SAN JOAOUIN COUNTY, —� <br /> "OoUNSHOME OWNER I O WCAED AGENT'S IATUgENCERTIFIES TIGN THHE FOLLOtMNGANI CERTIFY T AT IN THE PEgfp \ <br /> i16 ORNA.PERMIT 19 THE <br /> ISSUED,I SHALL NOT EMPLOY PERFORMANCE <br /> SUBJECT TO WORKMAN't COMPENtAT011 LAWS OF CAUFORNIA.• CONTRACTOR'S Hl�p 6UNBOpE6,STATE/AWS,ANO RULES ANO <br /> iE FOLLOWING: I CERTIFY THAT IN THE PERFOPMANCE OF THE WpPL FOR <br /> 4LIFORNIA.' THE APFl1CANT MWT CALL 2410 ONTRAC OF THE WOR(FOR WHICH <br /> WHICH THIS PERMR IS 18 LED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION <br /> IN ADVANCE FOR ALL RFOMRFp INtIRCTpgt 1fipALT�G SIGNATURE CERTIFIES <br /> pnetl X _ AT 12011 W/JI2], COMPLETE DRAWING AT LOWER AREA PROVIDED. LAWS OF <br /> ROT PAN Rkwv le �, One <br /> NAMES OF STREETS OR no NEAREST SPNeI III % •1e _f <br /> OLRUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH THE PFC KMN <br /> 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PI1D <br /> STRUCDIMENSTURES, <br /> NCLOUTLINESINN ANO LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL ,,B,EMS. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DPVEWAyS,AND WALKS POSED <br /> 6. LOCATION OF WELLS"MIN RADIUS OF ONE HUNDRED FIFTY PT. <br /> - ON THE PROPERTY OR ADJOIMNO PROPERTY. <br /> OEPMTMENT USE ONLY <br /> ellalbn Acvepletl Ry <br /> iW ImPenbn BY Dela ( /�, <br /> Deb Mee LLLYYY U / <br /> Pump Impaction By <br /> vmtbn ImpacOon BY Ona <br /> imenU: % 5 / Deb <br />;COUNTING ONLY: D <br /> FALs <br /> It CODES FEE INFO AMOUNT REMITTED CHECUMASH RECSY <br /> /1 DATE PFIIMR/tgLy10E REOUFiT NV,R861 <br /> V `S <br /> INVOICE <br /> TI pd 3�r3 <br />