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APPLICATION FOR WELL/PUMP PE (IT <br /> +N JOAQUIN COUNTY PUBLIC HEALTH w-;�RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NOWAUVNOAILE PERMIT EXPIREt 1 YEAR FROM GATE IsguEO F <br /> AP'LICATION to Hing By MADE TO THE SAN JOAOUIN COLINTy FOR A PEPI.IIT TO (comp <br /> ANO/OM JOAOINSTALL TF{[WOW DESCRIBED.Tule APPLICATION <br /> UN COUNTY D[V[LOPMENT TTTII,CIIAPTq 9-1115.3 AND Si ARD1 OF SAN JOAOUI"COUNTY PUBLIC"EASERVICE!, <br /> LTH "MPIONMENTAL HEALTH blVie ON.MADE IN IANCE WI7f I SAN <br /> JOB AD DRE/SroR APN/ <br /> OW1lEn'/NAME <br /> CRT'&— PARCEL SIZEIAPN/ ^ <br /> ADORES <br /> T'IONE I <br /> CONTRACTOR pwa <br /> PRONE/ <br /> PVA CONTRACTOR Zhu-me.9 1 LIC 37 <br /> ADDRESS <br /> 1Q—UC/ r`IIONf/ <br /> TYPE OF WELL/PVMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONEY ORINO WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CnOBO-CONNECT REPAIR ❑ VAPOR E%TMC7ION WELL/ <br /> 11 (®j� J <br /> N.w!`Rep.h M.P. DEPTH PUMP BET PT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> O <br /> ❑ OUT-OP-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ BOK BORING <br /> S <br /> ❑DESTRUCTION- <br /> INTENDED USE TYPE OF WELLCONSTRVCIION SPECIFICATION{ <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONOUCTon CASINO A <br /> n <br /> MMEBIICIPRIVATE GRAVEL PACK/SIZE TYPE OF CASINO/ITFELR'VC DIA.OF WELL CASINO O <br /> ❑ PISUCIMVNIC IPAL DRIVEN DEPTH OF GROUT BEAL SPECIFICATION 1, <br /> ❑ Inn[GA]10N/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAM[ �y E <br /> ❑ MONITORING —���((r�, GROUT BEAL PUMPED: ❑Y. [IN. CONCRETE PEMITAL BY DM-U t❑Y« �N. d <br /> APPROX.DEPTH �.W LOCKBIO Cliff?En/OXmTOVE PIP[ d <br /> PROPOSED CONITRUCTIONIDMLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE• OTHER <br /> I HEAERY CERTIFY THAT I HAVE PREPARED THIS AITIJCATON AND THAT THE WOFK WILL,at DONE M4 ACCORDANCE NAT"IAN JOAOVIN COUNTY On MMANC[/,STAT[IAWt,AND FM/LE/AND � <br /> nEOVLA710N9 OF TIE SAN JOAOVIN COVNtY, HOME O R OR LICENSED AGENT'/SIGNATURE CERTIFIES THE FOLLOWINGS h CERTIFY THAT W TM PEROFMAANCE OF Tiff WORK POR WHIG" <br /> THIS R'EnMIT 1 ED,I SHALL O PLOY PERSONS JECT TO WORKMAN'&COMMISATION LAW/OF CALIFOMSA.- CONTRACTOR'S MMM OR SUS-CONTRACTING SIGNATURE CERTOIE/ <br /> THE FOUo" G -I CERTIFY T IN HE PfFIFORMA OF THE WORK FOR WHICH THIS PERMIT 11111 D,I SHALL EMPLOY PERSONS SUSAECT TO WOMMA M'S COMPO/SAT10N LAWS OF <br /> CALIFORNIA. RI AAPMCANT ! NO ADV R ALL RSOUII 71 TIONS-AT 11 .9421, COMPLIit[DRANMd0 AT LOWER AREA MOVIOEO, <br /> 71110 — DN. <br /> PLOT PLAN M,&w to Boole)Be.l. •to <br /> 1. NAMES OF Bt REFT1 OR ROADS NEAREST TO OR SOUNDING THE PROPERTY, 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P110b1t0 <br /> 2. OUTLINE OF Tiff PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAO[DISPOSAL OYMMI, <br /> 7, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS M"MN RADIUS OF ONE HUNDRED FKTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PIOFERTY. <br /> ..... .. t ... .. .. e <br /> 1 7r <br /> -- ,� <br /> .. <br /> _ t <br /> 3 I <br /> 16f <br /> : <br /> . � <br /> MYMENTA <br /> . . PR <br /> �T,ti CG <br /> ENVI ON ENTA�N <br /> I �BERVIClB <br /> ... SAT ,L . . . . _.. <br /> �-r DEPM7MENT USE ONLY <br /> Appllo.tlen AeeepleA Py <br /> Grout Impeotl—Sy Dae Pomp In.peoti—By D.b <br /> Drr.lnretlon I-p-0—Ry D.1. <br /> Cemmer.N� <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FEE INTO AMOUNT REMITTED CHE //CASA REC19VED By DATE PERMITISETIVICE REOUESt Nl1MBFR INVOICE <br /> 4r4j <br /> �7 0 0 <br /> -Y3 3 <br /> Pub,Health So-.-Enviro.173(1/97) <br /> A.::, <br />