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APPLICATION FOR WELLIPUMP PERK <br /> v SAN JOAQUIN COUNTY PUBLIC HEALTH SE ICES PAYMENT <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388.904 EAST WEm AVENUE,sioac ONt CA moi. 011IVIID <br /> ROB) 488-3420 JAN 15 r;6 <br /> ZION REFUROAdLE PERMIT EXPMES 1 YEAR FROM GATE ISSUEDFlll3LIC M16TW��RV $ <br /> (Cs wb%b TrMlRnti) <br /> APRJCATIDH IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DEECRISED.THM U����� � ����� <br /> JOAQUIN COUNTY OEVELO RENT TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES.ENVIROMENTAL HEALTH DIVISION. <br /> Jos ADo1REsa/oIR API/ 5 7-7 w• 11" 5 <br /> T-rttT CITY T" L PARCEL smAPNI '15'..11y0 <br /> o1�INER s w- 11 i R T I i i mt&09 ADDRESS I ID a EI .9 .4 not I J�Mrr j��_ C`y/�'►j"PHONE s <br /> C� W- Ma r Ch L-rl- LICA _19 -0 <br /> awNlJ� �7to�`Env�LreN rn•h�'d� Amoss 140� M r -PHONE119 <br /> �EEcoNrRAcroR �I'I �^�M t L •M C- ADORES!11 .9© E• Fitts SON t. ° uc: ;I 9 Rw1oNE I <br /> TYPE OF'wa Mmm, ❑ NEw wELL ❑ REPLACEMENT WELL ❑ MONITORING WEu s ❑ OTHER <br /> ❑ PwALLATPoN ❑ wELL SYSTEM REPAIR ❑ CRosscONNECT REPAIR ❑ VAPOR EXTRACTION WELL e J <br /> ❑Now❑Ropok H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL d <br /> IrYPE OF PUMP) <br /> ❑ OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELLf! 10 son.BOFIINO S <br /> ❑R>ESTlIICTION: <br /> A <br /> n ft <br /> 13NIDUSTIEAL [3 OPEN OPBOTTOM DIA.OF WELL EXCAVATION /' DIA.OF CONDUCTOR CASING D <br /> ❑DOMESTICIWEVATE ❑GRAVEL PACK/82E TYPE OF CASINOMTEEUPVC v DIA.OF WELL CASING D <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL To SPECIFICATION p R <br /> ❑ WMAT10WAG ❑OTHER GROUT SEAL NISTALLED BY GROUT BRAND NAME POPI IU144 L+Ift 4N E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Y. IN Na CONCRETE PEDESTAL SY DRIUM❑Ys ❑N. S <br /> AplR x Dlril LOCKING CHESTER SOXJ/TOVE PIPE <br /> TM�. S <br /> FROFOSYI MST/DD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER V o r't Ct Plj 1; <br /> 1 HENIEdY CERTIFY THAT I HAVE PIEPAIED THIS APPLICATION AND THAT THE WORK WILL SS DONE NO ACCORDANCE WITH SAN JOACUIN COUNTY ORDINANCES,STATE LAWS,AND Mn AND <br /> REOIERATIONS OF THE SAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CEIRIFIES THE POLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK PON WHICH <br /> TMS PSIVAIT M ISSUED,1 SHALL NOT EMPLOY PEISONS SUS.tECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HMM OR SNMTUE CM,WWf <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOIGMAN'S COMPENSATION LAWS OF <br /> CAUFONN A..`�T�HE THE MUST CALL 74 NOUNS IN ADVANCE POR ALL REOIII�1NSgCTIOW AT IMI 4094422. COMPLE�T.DRAWING AT LOWER AREA PROVIDED. <br /> Blond X�'pw;' Tis. Sit t e N Staff G so 1 0 g 1 7 fyEDat. <br /> PLOT PIAN(Draw to Soalo)Seoh •t. T <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED, <br /> 2. OUTLINE OF THE PROPS rY.GIVING DIMENSIONS AND NORTH DNECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 1. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOIED FIFTY FT. <br /> STIRICTUIES,INCLUDING COVERED MEAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOMNIO PROPERTY. <br /> :.......:......:................... .. .. .. . <br /> ... .. .. .. .. . <br /> ...........................;.... .. .. . <br /> ... .......... .................................... ..............,.....................,...... <br /> I <br /> DEPARTMENT USE ONLY 9 <br />( Ap/So.tion Aeo.pt -J <br /> .d BY Dot / I ` ( 1p Ar <br /> Grout kupaotbn SY If L Dat. Impaction <br /> Do-uotlen kopwom Sy Date <br /> Com""wvto: <br /> ACCOUNIMO OLIY: AI01 FACS <br /> K CODES m INFO AMOUNT REYSTTED CHECK//CASH RECEVED SY DATE PENAT/SEMCE REQUEST NUMSEI INVM[ <br /> 7 <br />