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APPLICATION-F9R WE'40PUMP PERMIT <br /> °`SAN JOAGUIN COUNTY PUBLIC HEALTH SERVIcE'4 <br /> ENVIRONMENTAL HEALTH DIVISION 0 <br /> P.O. BOX 388„ 304 EAST WEBER AVENUE, STOCKTON, CA 95209-W <br /> (209) 469-3420 <br /> #()N—REFUNDABLE—p�-RMIT—EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION 19 HERE RY MAI (cot"ploll In 111pneviol <br /> )F TO THE SAN JOAOUIN COUNTY ron A PERMIT TO CONSTRUCT AND/on INSTALL THE WORK <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN DESCRIBED,THIS APPLICATION 18 MADE IN COMPLIANCE WrIj;51,L4 <br /> JOB ADDRFSSJOR APN* 10 Cj COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, <br /> /o CU, <br /> OWNER'S NAME <br /> PARCEL SIZEJAPN# <br /> ADDRESS 0�% P&7— <br /> CONT RACTO--ap-e--�C- r --------- Pt W-f <br /> F;US CONTRACTOR ADDRESS. tjc#;��llzco�,? PHONE it <br /> ADORFS8 ucff— PHONE <br /> TYPE OF ❑ NFvv WELL ❑ AFPLACFMFNT WFIL MONITORING WE.11. r <br /> ❑ 11 OTHFR <br /> El fNSI A[LATION WELL SYSTEM nlPAln ❑ cnoqS-CONNFCT REPAIR Cl VAPOR EXTRACTION WELL 0 <br /> IT YPE OF PUMPI E)New 11 Pormil, ".P.— OFFIT"Flump sEr--FT. FIRST WATER LEVEL <br /> ` <br /> EVEL j <br /> 11 OUT SERVICE WFI,L ❑ GFOPUYSICAL WELL# Son,sOnING <br /> XDFSTRUCTION!_prelq�'- jp !,3v'7v,,4 T- (3) ❑ <br /> —lz P61INIENOEp USE TYPE OF WEtC <br /> itummitivqUoN SPECI FIC=AMO`N�4 000000— <br /> ❑ INDUSTRIAL 0 OPEN BOTTOM DIA.OF WELL EXCAVATION A <br /> ❑ ­ <br /> DOME9TICIPRIVATE (3 GRAVEL PACKISIZF. TYPE OF CASING/STFr(/pVC DIA.or CONDUCTOR CASING T(-- v <br /> ❑ DIA.OF WELL CASING 0 <br /> PURLICIMUNICIPAL 11 DRIVENDEPTH OF GROUT <br /> ❑ IRRIGATION/AG 11 OTHER GROUT SEAL.INSTALLED BY SPECIFICATION <br /> ❑ MONITORING GROUT SFAI PUMPFO: GROUT BRAND NAME F <br /> APPROX,DEPTH Xy---d No CONCRETE PEDESTAL.By DRILLER- ❑No <br /> LOCKING CHFSTFn BOX/RTOVE rnpf_ <br /> PROPOSED CON@TRUCTIONIDRILLINQ METHOD: MUD ROTARYAin ROTARY--AUGER---CABLE---_OTHER <br /> 1 HER <br /> TItEkT I HAVE PREPARED THIS APPLICATION AND THAT T I4F WOW WILL BE DONE IN ACCORDANCE VAT"SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND Int—FSAt4n <br /> RI TIONS OF SAN JOAOUOIN COUNTY, HOME OWNER OR LICENSED AGFr4T*s SIGNATURE CERTIFIES TNF FOLLOWING:'I CFR71FY THAT IN THE PERFORMANCE OF THE WOW FOR MIIC�,4 <br /> TO rPEnMITIOISSU I 911ALI NOT EMPLOY PERSONS SUBJECT T"ORKMAN'S COMPENSATION LAWS OF rAlIFOANIA.' CONTAACTOn'g"IRINGORSUB-COMRACTINGSIGNATUnFCFMIFICr, <br /> PEIMFF SHALL <br /> I-' Tp <br /> ICE <br /> t OF T <br /> I H FOLLOWING: •I FITTIFY THAT IN TO AF j FOR VA41CII THIS PERMIT IS ISSUED,I$"ALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPIDIIIATION LAWS OF <br /> GHE A -AN'- I:- I <br /> CANT IV <br /> CAU NIA.' THE A MV IT C 0 Vj R ALL RFOLRRFO I I It At 12091460k-U23. COMPLETE DRAWING AT LOWER AREA POWDED. <br /> X <br /> IS I R. <br /> V <br /> X TItI. <br /> [).to <br /> ME'or PLOT PLAN fl),o-to S-J.)S­j. to <br /> 7 <br /> 1. NAMES Of ST ETS OR ROADS NEAREST BOUNDING Tiff PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL ayffTfm on pIV)MrjEo <br /> 7. OUTLINE OF Tiff PMPF.Frry,DIVING DIM NOI.AND NORTH DIRECTION. FXPA14031ON OF SEWAGE DISPOSAL SYSTEMS. <br /> I ST . R. <br /> 3, DIMENSIONED OUTI-INF.8 AND OCATID 7FAILIL EXISTING AND PnOPOSFD S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY F I <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY- <br /> ............. .... ........... . <br /> DEPAAIMENT USE ONLY <br /> ApplIcotle.Ae.epiori fv_ Dots— 110, <br /> amn lmpwfl"ev-- <br /> Cox <br /> j qlq <br /> p12 <br /> .ACCOUNTING atil ADD/ FAC# <br /> FE conts FEE ONTO AMOUNT AMIN T7 ED CHECK#/CA6N RECEIVED By DATE POWITRIERVICE REQUEST NUMpEFt INVOICE <br /> Z#T <br /> Pub,Health Serv.-Enviro.173(3196) <br />