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APPI SIN FOR WELL)PUMP PERMIT
<br /> SAN JOA&*. ,ADUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388
<br /> (209)468-3420
<br /> NON-REFUNDABLE PERMIT WIRES 1 YEAR FROM DATE ISSUED
<br /> ICempkfs In TlIplievis)
<br /> APILCATION IS IRRE RY MADE TO THE SAN JOAUUIN COUNTY Fan A PEnMIF TO CONSTRUCT ANDJOR 1NSTAIL INF.WORK DESCRIBED.TIES APPLICATION IB MADE IN commANCE WIT II SAN
<br /> JOAOUIN COURtY DEVEL�OfPM`E_NTT_TITLE,CIAPTEIR F0-1115.3 AND TIE SEAWARDS OF BAN JOAOUIN COUNTY PUBLIC
<br /> 11FALTII SE(VICES,ENVIRUNMENTAL FIEALT14 DMSIDN.
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<br /> OWNTO'S NAME1;1 '�er+Y'�0 �ADDRESS JOS N, (LLL YSX4.ES,L? IW HONE fy J
<br /> CONTRACTOR .S�)eG�r(�nj f5,r rr�fi T�1C, AUDRFRR a30 w/ lf/ m+ X ucf 5���6c�rylONFfo"179-�IbS' 71x�
<br /> FUR CONTRACTOR ,I----1I ADDOFRP. LIC/ }} Pilowrf
<br /> TYPEOFWELL/PVMP: ❑NFWWELL REPLACEMENT WELL �14--LwowonwnWELL• OtiIER P.fH A GWI-6W3
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<br /> INSTALLATION ❑WELL BYST EM REPAIR L CPOSS-CONNf CT REPAIR ElEL
<br /> VAPOR EXTRACTION WL/ J
<br /> I]m-1__l F-1, N.P, DEPTH PUMP RET_FT, FIRST WATER LEVEL O
<br /> (TYPE OT P'11MPI
<br /> ❑OUT-OE-SERVICE WELL ❑GEDPIIV61CA1,WELL 1 Lty SOIL
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<br /> ❑otsinUCTMN: 3&t"-i, i CQme*
<br /> INTENDED USE TYPE OF WELL CORN ANO
<br /> A
<br /> A
<br /> ❑INDUSIRIAL ❑OPEN SO TTOM DIA.OF WELL EXCAVATION DIA,OF CONDVCTOn CAPIND D
<br /> ❑DOMERTIC/A4VAIE F❑,--TT GRAVEL PACKIBI;E Nrt of CASINGMTE,EIMVC- DIA.OF WEI I.CAMNO D
<br /> ❑PURLICIMUNICIPAL 1_I DmVTN OEP111 OF GROUT SEAL SPECIFICATION p
<br /> F❑y rMnAl1ONIAG ❑OT14TR GROUT SFAL INSTALLED BY OnOUT BRAND NAME 1L----1I F
<br /> Ll MONITORING GRANT SEAL PUMPLo:[IV. ❑Na CONCRETE PEDESTAL BY ORILLEn:O Y- [IN. S
<br /> APPRO T hr"" LOCKING CRF Ef fR SOXNJTO VE PIPE {� S
<br /> PROfVAEO COPIEERUCTICNIDPELVNO MET"ov: MUD ROTARY AR ROI Any AUOFTI CAIRF OTHFR--✓ rt-_
<br /> r Hf4t4Y CERTIFY THAT I IIAVE PREPARED THIS APMJCATION AND TIAT THE WORK WALT BE DONE IN ACCORDANCE WLTH PAN JOAOUIN COUNTY ORDINANCES,STATE UWP,AND RLRFS AND
<br /> RFGUI ;01BAN JOAOVIN COUNTY-ROME OWNED OR UCENPED AOLNT'R SIGNAL On, :Em FIEf5 TIIE FOLLOWING:'I CIMIFY THAI IN THE PFRFORMANCF OF TIIE Wo,K Ton wtnCl1
<br /> TIO KRAIT I S11AI L NOT TMPLOV PERRONR SUBJECT TO WORKMAN'■COMPENSAT1um LAWS OF CALPrURNM.'CONTnAC1On'R AIMING On PUB-CONTMCTINO SIGNATURE CERTIFIES
<br /> TII ESTLOWERTL"TRAT IN TIIE TEWOIIMANCE OF THE WORK TOR WHICH THIN PERMR IS ISSUED,1 PIIALL FMfEOV PERSONS SUBJECT TO WORI(MAN'•COMPENSATION LAWS OF
<br /> CA nmA CANT MINT AL1 24 HOUR IN ANCE FOR ALL REQUIRED INl�,f.E//fy.TRONA AT M'M1 44R JAI'.COMPLETE ORAWINO AT LOWER AREA ITLOV, En. {�
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<br /> PLOT PIAN R1,ww en P•,.N.1 Re:•Ie In
<br /> 1,NAMFA OT RTRFFTO OR SOADP NEARES T R BOUNDING TRE EYI/1Yn(Y. 4- LOCATION OF NOVRT BEWAGE DIAPOSAL SYPTFM OR PRO,n REO
<br /> 7.OUTLINE OF TIIE fROPFRTY,OMNG OI E IONS ANO NORTH DIRFC T InN. EXPANRION Of FEYWAOE DISI.OSAL RYPTEMS.
<br /> ].DIAFNVM"'D ONTLBJED AND LOCATI OF ALL EXISFRJO AND ry Mgrn E-LOCATION OF WFLLE WTIIIN RAOIVS OF ONE NUMnRED TTTY FT.
<br /> STRUCTURFS,INCIUOINO COVERED AREAS SUCH All PATEOG,DRIVEWAYS,AND WALKS- ON TIIE PROPERTY OR ADJOINING PROPERLY,
<br /> CHANNEL. ST
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<br /> SOIL,SEDIMENT,WOOD AND GROUNDWATER
<br /> SAMPLE LOCATION MAP FIGURE 3.1
<br /> We6[r BIPTE(Area
<br /> ,w.w^^'"""-_-" Yw"R""•'^4°`^•^"�'^"'"'_ _ Slx Lton,San 1q.i.[Sooty,,
<br /> Californu
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<br /> DF.PARTMMT VEE ONLY
<br /> Appllcr n At I-I,f RF D.J.
<br /> OrPUS 1rwPwcllon nY In— Tlane In•AAellwn TY pHe
<br /> Om1r,P.ttnn Imnw-ll�m BY b•te
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<br /> ACCOUNTING ONLY: N01 FACE
<br /> FE COVES FEE INTO AMOUNT RIVATTED CtIECKOMASH RECEIVFO Illy DATE FERAIPTriEnVICE REOUERT RINSER Iwolcf
<br /> �4� Z
<br /> Pub.Health Serv.-Enviro.173(3136)
<br />
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