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r <br /> g ULICATION FOR WELLIPUMP PERMIT <br /> 5,... JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH REVISION <br /> µ <br /> P.O. BOX 3K 304 EAST WEBER AVENUE, STOCKMN, CA 95MI-W wl <br /> 12091408-3420 'r <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {C$mpl$te In Triplic$1$I <br /> APPLICA?ROH 18 HERE by MADS td THE DAN JOAQUIN COUNTY FOR A PERFAtr TO CONSTRUCT AND/OR INSTALL THE WORK DESCFVBED.THIS APPLICATION IB MADE IN COMPLIANCE WIT 11 SAN <br /> JOAQUIN COUNTY bEY£LOPMENT.tITtk,CHAPTER 9-1116.3 AND THE STANDARDS 0 SAH JOAQUIN COV PUBLIC EALTH SERVICED,ENVIRONMENTAL HEALTH DIVISION. <br /> ''A AbI74ssmii1 022-112, CiTY dG' PARCEL SIZFJAPN# <br /> n,"4 NAMW WWAA4114, ADDRESS A PHONE I <br /> `CoNTRA1c`TORADDRESS • • '�� - � CA'�.15�91_,�PFWNE I <br /> ,, FfI1rRACYOR - ADDRESS LIC• PHONE I <br /> k' <br /> . x�,,.. UMP' ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORINO WELL• ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ' •;5 !+;" ❑ DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ©Naw Repel, H.P. <br /> :;FtYPE.OF PUMPI ������ <br /> OVi-DF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING -' S <br /> RUCTION: <br /> 'I"�I--yy ED U$E YPE OF WELL GON$TRl/CTION SPECIFICATION$ A <br /> bi <br /> L:J'IWbUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION GIA,OF CONDUCTOR CASING D <br /> �µµ)�v} TYPE OF CASINGISTEEL/PVC DIA.OF WELL CASINO D <br /> t LJ OOAAESTIClPRIYATE ❑GRAVEL PACKlSiZE <br /> {{� Uit1CIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> AS +.)) GROUT BRAND NAME E <br />��`.� IRRiGATK)NlAG ❑OTHER GROUT SEAL INSTALLED 6Y <br /> d:MONITORING GROUT SEAL PUMPED: ❑Yee ❑Na CONCRETE PEDESTAL SY DRILLER:❑Yr ❑Ne S <br /> iii `�" <br /> �` LOCKING CHESTER BOXISTOVE PIPE S <br /> Ir,ApPpp7f,DEPTH - <br />�'. .; <br /> PROFOEFD CDNSTRUCTIONIDFgWNO METHOD; MUD F10TARY AIR BOTANY AUGER CASLE OTHER ` <br /> j!I,HECIEBY CERTIFY T' AT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 1N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND <br /> RULES AND <br /> 60 'TIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> F,,fwd PEMI[IT IS ISBl1ED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> tHS i OLLOWINo: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />;ti' FO A.* THE APPLICANT MUST CALL <br /> 22444 HOURS IN VANCE FOR ALL REQUIRED INSPE.CTTION&AT 120$1 4M-1421- COMPLETE DRAWING AT LOWER AREA PROVIDED- <br /> //,I <br /> ROVIDED. <br /> Till <br /> Dete//t ,1 ;7, i <br /> PLOT PLAN(Drew to DoWill Scale 'to <br /> r'•^Y' 4, LOCATION OF HOUBE SEWAGE DISPOSAL BYSTEM OR PROPOSED <br /> N�I: H/IMEB OF STHE Pn OR ROADS NEAREST NS OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE 019POSAL SYSTEMS, <br />;.r.,1;'OUTLINE OF <br /> THE pROPElYTY,GIVING DIMENBIOHB AND NORTH DIRECTION. S, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br />�j{i, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY• <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS- <br />,., .. ., <br /> . <br /> s }. <br /> LAYMEN' <br /> f •w - <br /> y I. .. - - <br /> _ OCT 2 7 X995 .... . <br /> SAN JOAOUIfd COUNTY--.•-'. <br /> A <br /> L�HEALTH DIV SIGN <br /> "-. DEPARTMENT USE ONLY _ •� <br /> ( � Area <br />�'f:'; ��✓� bete - �, <br /> 2-.-4 Application Accepted BY <br /> Pump Impaction BY , <br /> 'gii;4..Grout Iropectlon DY Dote C f <br /> 1 . <br /> bect+uctlan Irupeetlon BY <br /> ., Comma u: <br /> AID# FAC# <br /> ACCOUNTING ONLY: INVOICE <br /> I PERMITISERVICE REQUEST NUMBER <br /> !�• ryry CHECKlICABH RECEIVED BY DATE <br /> ' �,5,..`r ;I'E CODES FEE INFO .� <br /> AMOUNT REMITTED /) , <br />