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APPLICATION FOR WELLJPUMP PERM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERWCES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. Box m 904 EAST wEm AVENUE,sTomoN, cA quol-m PAYMENT <br /> (209) 4e8-U20 RECEIVED <br /> A <br /> NOWT NUNDABLE PERMIT EXPIRES 1 YEAR INN DATE ISSUED I�� � �� q <br /> 0"IS1S In Trbluft) NAts wm cu � ry <br /> APPLICATION IS HERE BY(MADE TO THE SAN JOAOLHN COUNTY FOR A PERMIT TO CONSTRUCT ANIWR INSTALL THE WORK DESCRIBED.THIS SAN <br /> JOAOUN COUNTY DEVEL.OPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, LrP o%*w4 i :'y'1 iI ON <br /> JOB AODIESNDIE APO# 5 15' W, t l Lh 5 T r«T CITY T►^Q L y PARCEL 81MAPN# ► o+x t l{O R <br /> I i s k BlLrbt ADDRESS S)V+{4 LM 5 V l )vw L neAsKI T PHONE <br /> w4wll V'dNL E11v1 r ! AODIEse t403►�' M41Y h �/� 7 LJc. PHONE. 5,6-0 <br /> AOR pr1)I -WiNCJhc, ADDRESSII)LsOE.A••�1a� L�+M!)ILCs697114 PHOEos�}q-�IT� <br /> TYPE OF WE.LRUW. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J <br /> (TYPE OF PUMPI <br /> 13 N.13VEL R,potr H.P. DEPTH PUMP SET FT. FIRST WATER LEd <br /> Lp� <br /> 13SE <br /> OUT•oF- RVICE WELL 13EO <br /> GEOPHYSICAL WELL# 13 SOIL BORING e <br /> ❑oESITILRCTION: <br /> 13INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION RL DIA.OF CONDUCTOR CASINO D <br /> ❑DOMESTICIPNVATE ❑GRAVEL PACKMZE TYPE OF CASNGMTEEUPVC DIA.OF WELL CASINO D <br /> ❑ PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL T p SPECIFICATION I <br /> ❑ ISSGATKIwAG ❑OTHER GROUT SEAL INSTALLED BY L7'' GROUT BRAND NAME P#CT)f L•atts+r.T E <br /> 13 MONITORING GROUT SEAL PUMPED: [3Y« Us, CONCRETE PEDESTAL BY DRUMI:❑V. OW s <br /> APPROX.OEPTN LOCKING CHESTER BOXATTOVE PIPE s <br /> PROPOSBD COIISTLNICTIONIDRILUNG MRHOD: MUD ROTARY AIR ROTARV AUGER CABLE OTHER Dip" <br /> 1 NEmBY ceffn•Y THAT 1 HAVE"HARED THIN APPLICATION ANO THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> RBBULA"ONB Of THE SAN JOAOLIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT INTHE MWORMIANCE OF THE WOW POR WHICH <br /> THIS PERMIT M MWE),1 SHALL NOT DAMN PERSONS SUBJECT TO WORKMAN'S COMPINSATLON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING on OUB.CONTRACTINg SIMATURE CERITIFES <br /> THE FOLLOWINS: 'I CERTIFY THAT IN THE PEM'OOIMIANCE OF THE WORT(FOR WITCH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORT MAN'S COMPEINLTION LAWS OF <br /> CALWORM&* THII APP'UCCANTgM �NM ("0141004422. PL <br /> UST CALL 84 HOURS IN ADVANCE FOR ALL 1116" SCTIONS AT("014i422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> www X 9%plSL _!�Lt/'�0"A% TUI,5111 i•r 510 f f (J•o�a�i 4 D.t. <br /> PLOT PLAN PXSW to Bor.)Somh to <br /> L. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF MOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GONG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> .. . <br /> S <br /> .. . <br /> t .'.................. .. .. .. .... ..<... <br /> ..:... <br /> DEPARTMENT USE ONLY '] <br /> j_�_'I— <br /> ooton Ao-PW ST— 11—A ooa , L Ano <br /> MPe <br /> deut +M ` I Do, ! hMP�L +tIp Goa <br /> o..hueaen krr.otlen Sr Data <br /> Commonb: <br /> ACCONNTOG ONLY: AID/ FAC# <br /> K CODISI m NFO AMOUNT RYMTTED CHIICK#1CASH "cam BY DAIE PeMMTI WNM P"wT NLMEI INVOICE <br /> 3SO <br /> ::z <br /> - , <br />