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f <br /> ti <br /> APPLICATION FOR WELLIPUMP PERMIT 7-- <br /> SAN <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON,CA 95202 00 T 27 i'99e . <br /> (209)468-3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER — _..• .''. <br /> ICampiate In <br /> APPLICATION IS 91CM BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AMOIOR INSTALL THE WORK DESCRIBED.TFRS APPLICATION I8 MAGE IN COMPLIANCE WITI1 SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 97�4-1 115,3 AND THE STA OF AN JOAQUIN COUNTY PUBLIC H TH SERVICES,ENVIRONMENTAL HEALTH DM(SSIION. /,�•�7� <br /> JOB ADOREBB/OR MPH/ ,,y s CITYjoapPARCEL SIZEIAFNI 1 ALJ ! v I <br /> OWNER'#NAME L tI��J,�T ADDREB6 - . 5r'l plp ,M 7 A .. <br /> CONTRACTOR � ADDRESS <br /> SUB CQNfp11CTDR � ADDRESS <br /> TYPE OF WELIIPUMP: NEWV WELL ❑ REPLACEMENT WELL MONITORING WELL N OTHER i' <br /> ❑ INSTAt AT10M ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR~bra❑ VAPOR EXTRACTION WELL 1 d i <br /> ❑N...❑RepW N.P. DEPTH PUMP SE7 Ff. FIRST WATER LEVEL p ,j <br /> (TYPE OP PUMP) <br /> © OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL if Cl SOIL BORING g <br /> i <br /> ❑DESTRUCTION: L <br /> INTENDED USE TYPE OF WELL CONSTRUCTION APECIFTCAT30M8 A ' <br /> ❑ INDUSTRIAL C❑O/PSN BOTTOM DIA.OF WELL EXCAVATION If GIA.OF CONDUCTOR CASING 0 <br /> 11OOMEBTICIPRIVATE L_7 1AIEL PACfCtB*t /-+ TYPE OF CASIHOISTE DIA.OF WELL CASINO Z�. 0 <br /> ❑ PUBLICIMUMCIPAL ❑ORIVETI DEPTH OF GROLIT SEAL - SPECIFICATION R I <br /> ❑ iiSRHiATIONIAA [3 OTHER GROUT SEAL#TOTALLED BY �� GROUT BRAND NAME_„ ♦ E Y <br /> MONITORING �� GROUT BEAL PUMPED: ❑Yr 114. CONCRETE FEMSTAL BY ORRLER:❑Yr ❑Ne 5 <br /> APPROX.DEPTH ^. ......� LOCKING CHEST OVE RPE S <br /> PROPOSED CONSTRUCTIOMAMUPM METMOO: MUD ROTARY AIR ROTARY AUGETL CABLE OTHER <br /> 1 HE-*BY CERTIFY THAT 1 tIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUMTY ORDINANCES.STATE LAWS.AND RULES AHD i F <br /> MOULATIOHB OF THE BAN JOAOUON COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CER, FES THE FOtXOVVING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH- <br /> THIS PERMIT IS ISBUEO.1 814ALL NOT VAPLOY PERSONS SUBJECT TO WORKNIAN'S COMPENSATION LAWS OF CAUFORMA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERFIFDEB <br /> THE FOLLOWING. 'I CERTIFY THAT IN THE PMWONOMANCE OF THE WORK FOR WHICH TFRS PEFUM 18 ISSUED,1 SHALL EMPLOY PERSONS BOWE&TO WORKMIAWII COMPENSATION LAWS OF <br /> CALIFORNIA.- THE <br /> /)AP/MJA/.MT-MUST ST A HO k1N ADVANNCE FOR ALL REOUIR�GIs TIONS AT f2M 404-31423. COMPLETE DRAWING AT LOWER AMA PROVIDED. <br /> @*,d X- , '"�W TIhir Dat,_ <br /> PLOT PLAN BOr.w to Seel.l Salo <br /> 1. NAMEB OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> !. OUTLINE OF THE PROPERTY.GIVING OM"INSIONS AND NORTH DIRECTION. EXPANSION OF#EWAOE DDSPOBAL SYSTEMS. .4 <br /> 3. DIMENSIONED OUTLINES AND LOCATION Of ALL EXIffro L AND PROPOSED - S. LOCATION OF WELLS WITHIN RADRFS OF ONE HUNDRED FIFTY FT, <br /> STRUCTVREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WALKS. ON THE PROPERTY OR ADJOINING F7FIOPEILTY. <br /> .. ..- - - <br /> he <br /> DEPARTMENT USE ONLY <br /> Appketlen Aeeepted BY _-- — 0.t. 0/C� Arm� °•� r <br /> Grout Mnpeetlan BY Oete Pt+np Impeadon BY Date -` <br /> D..tniatlen Imowtl.n BY D.De <br /> CA//�� <br /> ar.vns.F.: f'TYf LCI .3L1 • r - <br /> ACCOUNTING ONLY: AW FACS <br /> FE CODES FEE INFO AMOUNT FlDMTTED CHICOICASH RECEIVED■Y DATE PH1041TISERWCE REQUEST MOWER INVOICE k <br /> 4 <br /> Pub LIGalth Selo.-EDvirO.173(1197) i <br /> N <br />