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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION R(-�S <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201.°88 <br /> I2991 466.3429 <br /> NOWREFUNOABLE PERVIT EXPIRES 1 YEAR FROM OATF ISSUED <br /> ICampNtE In Tro ketal <br /> APPLICATION 19 HERE DY MADE TO THE SAN JOAGVIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAI <br /> JOAOUIN COUNTY DEVELOPMENT TrTLE.CNAPTf 9-1 115,3 AND THE STAND ROS F BAN JOAOUIN COUNTY PUBLrC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDflES1lD APNI CITY /�(I C. Y PARCEL 812E1AR1/----------" <br /> OWNER'S NAME � � ` AOORESS PHONE/ I <br /> CONTRACTOR c�? C.� ADDRESS �- GCI _ PHONE t 1 <br /> BUB CONTPACTOR ADDRESS GCI ONE <br /> TYPE OF WEUJMMP; ❑(')j1EW WELL ❑REPLACEMENT WELL ❑MONITOAPNO WELL I ❑OTHER <br /> ?4�INBTALLARON ❑WEL TEM REPAIR <br /> ( ©CPA BBCONHECT AIR ❑VAPOR EXTRACTION WELL <br /> ❑Nw.❑Re I / H.P. DEPTH ROMP BFT�FT. Fm6T WATER LEVEL / <br /> A YPE OF PUMP i <br /> of`t'F-� ❑OUi-0E-BERVIC{µ+EHL LJ OEOMYBICAL WELL 1 Cl SOIL BOOING R <br /> ❑bEBTRUCTION: t_ <br /> j� INTENDED Ulf. TYPE OF WELL CONSTRUCTION SPECIFICATION/ A <br /> e ' OUBTMAL ❑OPEN 50TTOM INA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 'D <br /> DOMESFICIPRIVATE ❑GRAVEL PACKIBiZE TYPE OF CASINOATEEUPVC DIA.OF WELL CASINO <br /> ❑PURUCR4UNICIPAL ❑DRIVEN DEPTH OF GROUP SEAL BPECIFICATtON R <br /> ❑INRIOATIONfAO ❑OTHER OROVT SEAL INSTALLED BY GROUT BRAND NAME �yf <br /> ❑MONITORING GROUT SEAL PUMPED:❑Yw ❑Ne CONCRETEPEDESTAL8YWILLER:OYw ON. S, <br /> APPROX.DEVTH LOCKING CHESTER SOVITTOVE RPE �S <br /> PLOPOSEp CONSTRUCTLONB7Nt11N0 METHOD: MUD ROTARY AIR ROTARY AUGER CA9LE OTHER <br /> i <br /> 1 HEREBY CERTIFY THAT r HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOACUIN COUNTY DRDINANCER.STATE LAWS.AND RULE*AW <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIPES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WO'R FOR <br /> NASCI <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS 8tJ9JFCT TO WORKMAK'S COMPEISATIOM LAWS of CALIFORNIA.'CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THEE PEAfORMANCE RI <br /> OF THE WoW FOR WHICH THM PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SVBJECT TO WOO,MN'S COMPENSATION LAWS OI <br /> CALIFORNIA.' PPUCANT MVS 24 HOURS IN ADVANCE POR ALL REORARm Pmar%cTIDNS AT I20*14M4/21.COMPLETE DRAWING AT LOWER AREA PIOVIOE <br /> ROT PUN tDrrx[.Se.I.I Sul. •1. <br /> 1. NAMES OE STREET*OR ROADS NEAREST TO OR SOUNDING THE PTIOPERTY- 4, LOCATIDN OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2,OUTLINE Of THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL*YSTEMB. <br /> O.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY PT.' <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIvEWAYe•AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> -. ... -- <br /> .. <br /> .... <br /> ........... ........... <br /> , ....... <br /> mac ...` <br /> c�1� <br /> ............ .... ........... <br /> .......... <br /> ............... .......... <br /> ............... <br /> .. <br /> --, ..... .... :... .r 7 . <br /> ........ <br /> ............ ........ <br /> 9 9 6 <br /> ........... .............. .... <br /> ........... <br /> } AL <br /> aC <br /> v 7H <br /> }d M-T,.DiVry . <br /> DEPARTMENT USE ONLY <br /> APv1e.n..A.nml.d er -C_--�-_ D.I. �Ai« Z/ <br /> O'.i.lmv.ctlan BY Dae PUTP rnprtl.n SY D.t. CV. <br /> O.1-1w—I-p.mfa.BY DO. <br /> CBmm..+1+ <br /> AGO—. AIOI FAC' <br /> PE GODES FEE INFO AMOUNT REMITTED OHEC !CASH K..CVED eY OATS P9NOTISCVVICE RrZUElT NUMBER INVOICE <br /> I-. 05 +E 548'7 ter! 4/t, i�C'jl <br />