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APPLICATION $OR WELLIPUMP PERINI <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER..,aES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 988, 9 x EAST WEBER AVENUE, SMCKTON, CA S52pI W <br /> (206) 468.3420 <br /> ft0�1•REFUNDABtE PERIMIT EXAlRES f YEAR FROM DATE ISSUED <br /> < APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTIANDION STALL C(OPY <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1715.3 AND THE STANDARDS OF SAN JQAOUIN COUNTY PUBLIC HEALTH SERVICER, IS APPLICATION <br /> HEALTH DIVISION. <br /> 711E WORK <br /> DESCRIBED.THIS APPLICATION IB MADE IN CpMPUANCE 1M 14 SAP <br /> JOB ADbR SSMilt APNI151 ,A � <br /> V CITY ()!pI PARCEL SVEIAPN/ <br /> OWNEA'8 NAME q/ �r��,:� <br /> IV 1C <br /> TOADDRESS i eP <br /> CONTRACR , PHONE I a <br /> ' U � B � <br /> BUS CONTRACTOR AbDRESr LLC,-1Z/ 2-./— PHONE I <br /> ADDRESS <br /> LICIr PHONE 0 � <br /> TYP OF UMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I� __ <br /> C3 INSTALLATION ❑ ❑ CR <br /> INSTAATION WELL SYSTEM REPAIR E3 OTHER <br /> ❑ H.P. O$8 CONNECT REPAIR 13 VAPOR EXTRACTION WELL I <br /> (TYPE OF PUMP) New�Repalr I DEPTH PUMP SET FT. FIRST WATER LEVEL J <br /> WELL# ❑ <br /> - O <br /> ❑ GEOPHYSICAL BAIL BORING <br /> 13 DESTRUCTION; ❑ OUT-OF-SERVICE WELL 9 <br /> INTENDED USE YPE DF W <br /> CONSTRUCTFpN BPECIRCA710Ng <br /> 13 INDUSTRIAL OPEN BOTTOM A <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE DIA.OF WELL EXCAVATION TYPE OF CASINGCIA.OF CONDUCTOR CASINO f <br /> ISTEEL/PVC D <br /> ❑ PUBLICIMUN'ICIPAL ❑DRIVEN _ DIA.OF WELL CASINO D <br /> DEPTH OF GROUT SEAL <br /> tRAIGATION/AG ❑OTHER SPECIFICATION R i <br /> ❑ MONITORING GROUT SEAL INSTALLED BY <br /> GROUT SEAL PUMPED: [IYes [3 No <br /> GROUT BRAND NAME <br /> E 1 <br /> ., APPROX.bFJrTH CONCRETE PEDESTAL$Y DRILLER:❑Yre [3N. g <br /> ,. PROPOSED CONgTRUCTION/DRILUNO METHOD: MUD ROTARY LOCKING CHESTER BOX/STOVE PIPE��� <br /> AIR ROTARY AUGER S <br /> a CABLE OTHERj_� <br /> << I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATON AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULER ANq <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIONATUAE CERTiF1E6 THE FOLLOWING:"1 CERTIFY THAT IN THE PERFORMANCE E THE WORK FOR WHICH <br /> THIS PERMIT N ISSUED,: "IC I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'g HIRING OR SU"ONTRACTINO SIGNATURE CERTIFIES <br /> Z THE FOLLOWING: ')CERTIFY THAT IN THE KRFORFMNCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIOMAN•g COMPENgAT10N LAWS OF <br /> CALIFORNIA.' THE ANPUCANT MUST C 2<HO IN ADVANc FOR ALL REQUIRED INSPECTIONS AT 12091409 1, CQMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed X q � � <br /> Title <br /> i .. Date���. <br /> PLOT PLAN[Draw to SmI Smote to- <br /> STREETS 1• NAMES OF STREET$OR ROADS NEAREST TO Oq DOUNDINO THE PROPERTY, <br /> 2. OUTLINE OF THE PROPERTY,OFVING DIMENSIONS AND NORTH DIRECTION. 1- LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOBEb <br /> • 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE C40POSAL SYSTEMS. <br /> ,, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOSDRIVEWAYSAND WALKS. S. LOCATION OF WELLS WITHIN RADII OF ONE HUNDRED FIFTY FT. <br /> 1 ON THE PROPERTY OR ADJOINING PROPERTY. <br /> :-.. <br /> Ick <br /> ... <br /> 1, ► : .. <br /> L <br /> 1 .. __- ., ,.....i. ..: .... ........... ' - L.I�vIRON ff.. }�4HL V�tt .-L.L � I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Dole Ates <br /> Oravl Inspection 8y p to Pump Inspection By rf r 4'7 <br /> Dote <br /> Destruction Inspection By - <br /> Dote <br /> Commor"w <br /> rCOUDSA <br /> ING ONLY: AIDI FACT <br /> 'i <br /> FEE INFO AMOUNT REMITTED HECIGRIC BH RECEIVED BY DATE PERMITIOERVICE REQUEST NUMBER INVOICE <br /> a i D3(p15� <br />