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-r APP1 {ION FOR WELLIPUMP PERMIT ' <br /> USAN JOA6 COUNTY PUBLIC JEEALTH SERI _S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ! P.O.BOX 388,304 EAST WEBER AVENUE,8TOCKTON,CA 95201-ee <br /> (209)4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICampMh In TRIpTN:atal <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBEO,THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN , <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115,3 AND THE STAHDA%'lDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODREBNOR APNF CITY Tracy PARCELetmAPNE 250-200-01 <br /> owkws NAME- Coelho AODRrae7474 W. 11th St. ,Tracy T4z�31�a�MEMB'35-2,,�2,i <br /> cGNTRie7oR M a27" 74-281 5 <br /> f ADDRERRQO ]fox 51 .RioVisbao, 56E� <br /> eve CO <br /> rRACTOR J� - ADDAESS UCO PHON!r <br /> PE OFT. MP' ID NEW WFL,L ❑REPLACEMENTWELL MONROWNo WELL O 4-8,1 01 ❑OTHER <br /> - ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSH-CONNFCT REPAIR Q VAPOR EXTRACTION WELL F <br /> - <br /> (TYPE OF PUMP) 13 .p <br /> Ik.❑R .b H.P. DEPTH PUMP BET VEL PT, FIRST WATER LED <br /> - <br /> ❑DVT-OF-SERVICE WELL ❑GEOPHYSICAL WELL r ❑ SOIL SORINO <br /> e <br /> ❑DESTRUCTION: - <br /> INTENDED UINI YPE OF WE CON{rgUCIIOH APLCIFICATIOR{ <br /> ❑INDUNTRIAL ❑OItN BOTTOM OrA.Or WELL FXCAVATHIN R_o tt OIA!pTCONDUCTtM Cl1SINN�1S 711 D <br /> ❑DOMESTICA"VATE ❑GRAVEL PACKINIZE TYPE OF CASINO/STFELAA sch 40 PVC DIA.OF WELL CAGING_? n II ... p <br /> ❑PUeL1t/MUNK:IPAL C0 <br /> 1 pBIVEN DEPTH OF 6SOlJf SEAL_Pj�h 1 w!_j F,I_ f�P Pp SPECIFICATION - R <br /> ❑ISPoOATIONIAO pFI OTHER GROUT BEAL INSTALLED GROUTA <br /> BRANS N ME E <br /> 9 MONITORING GROUT BEAL PUMPFO; « Cl Na CONCRETE PEDESTAL eY DR ILUM-0 yO. ❑H{ a uP <br /> APPRox,mrTH-TIQ_1]p def-t-7-mined in field. LOCKING CHESTERSOXISTOVEPIPETYC rated box s <br /> PROPOSED C014$TRUCTIOII1dBWNO METHOD; MUD ROTARY AIR ROTARY AUGER•`CABLE OTHER .x$ <br />'t 7 <br /> 1. I HEAEffy CERTIFY THAT t HAVE PREPARED THIN APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE&STATE LAWS,AND NUIEB AND ' <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER ON LICENSED AGENT'S SIONATUIF CERTIFIED THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,i SHALL Not EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR CUB-CONTSACTOM INGNATUR6 CEIRIFMES <br /> THE POLL '1 CERTIFY THAT THE PERFORMANCE.OF..THE WA�ORL FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT To WOR IGMAN S COMMMSATION LAWS OF <br /> E CALFOSNI 'E 1ypR1�T Si U CA N HOURS IN ADVANCE FOR ALL REQUIRED <br /> �J171fECTIO/N},A7){2a 14694123.COMPLETE DRAWING AT LOUVER AREA PAOVrDED• <br /> If eterod% J/� 718._/��"(K(•'*�"�[ .,... b.1. ......_.: <br /> PLOT PLAN(Or—Ip Sn.I.1 6-1. 'to - <br /> f t. NAMES 111111 111 oR ROADS NEAREST TO OR BOUNDING THE PROPERTY. ♦. LOCATION OF HOUSE SEWAGE DIO OM SYSTEM OR PROPOSED - <br /> f 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM$. <br /> 3.DIMENSIONED OUTLINFS AND LOCATION of ALL EXISTING AND PROPOSED e.LOCATION OF WELLS WR`HIN M131US OF DNE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY ON ADJOINING PROPERTY, <br /> SEE ATTACHED" . .. <br /> Y <br /> ..... ......,, .. .. <br /> . . <br /> v <br /> 1^: <br /> DEPARTMENT USE ONLY <br /> Appuenbn A,c-m d BY Dae A," <br /> GrmA 1n.pr�c1lan BY Dae et <br /> 4A..,_ _Pp Imp«lion By �B <br /> YYCC im � <br /> bnNwtl.n Ir.p«Ibn By d.e. <br /> Cpmm{nN; <br /> ACCOUNTING ONLY: 916! PACO <br /> PE CONE$ FEE INF AMOUNT BTM! TED C11�1 �HE]CXIICAS - RECE"O BY DATE PWMTIAMMCE R VEST NINIM8ot INVOICE <br /> U <br />