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�U <br /> APPLICATION FOR WELLIPUMP PERMIT o <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O, BOX 588,304 EAST WEBER AVENUE,STOCKTON,CA 95201588 <br /> 1209)488.3420 <br /> NON-AEFUNOABI.E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICempkt{In Trlpikst{I <br /> APPLICATION I8 HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PEMAIT TO CONSTRUCT ANDJOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH DAN <br /> JOAGLIN COUNTY DEVELOPMENT TIT-LE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOLIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH D4VIS10N. <br /> JOB AOORESSAOR APNF CITY I PARCEL SIZE/APNF <br /> OWNER'S NAME } Y1 AOOPE98�l(C�pO/(�f. �C/ J/gc�� J PHONE lz 3 <br /> CONTRACTOR V LI / C J R I l l) K l ADDRESS Y-JOY�y� HJT / ! UCA X917 l3p"ONE 13&qJ 2�Jg <br /> BTI"CONTRACTOR ADDRESS UCF PHONE F <br /> TYPE OF WE1L1'l1MP: NEW WELL OREPLACEMENT WELL ❑ NIDNADRING WELL F ❑OTHER <br /> c ❑NDTALIATION ❑WELL SY TEM REPAIR ❑ CROS&CONNECT REPANI ❑VAPOR EXTRACTION WEgL'L�F <br /> 7/J gN-0 P—J, HP. 7 DEPTH PUMP SETZMFT. FIRST WATER LfVEL [/ O <br /> RYPE OF PUMP) <br /> �T❑OUT-0E-SERVAI-CcF WELL R❑G.EO�P/HYMCAL WELL F ❑ SOIL BOPoNG <br /> �E91RUCTION: 1 (A)(�// I (�yK ! J'1' M L l�]�} 1L� 12 I <br /> INTENbED ULE TYPE OF WELL CON{TFI=ILON■PECIRCAIION{ A` <br /> ❑INDUSTRIAL CJ OPEN BOTTOM /� DIA,OF WE1L EXCAVATION f DIA.OF CONDUCTOR CASINO p� <br /> ❑DOMESTO/PNIVATE �6RAVEL PACK/BQE /7 TYPE OF CASINO/STEEVPVC P V G DIA,OF WELL CASINO 4 p <br /> ❑PUSUCAAUNICIPAL ❑DRIVEN T-- DEPTH OF OUT SEAL , <br /> I� 6PECINCATION q 5 <br /> IA IRRIOATgN/AO El OTHER Gi1b VT'� E <br /> GROUT BRAEEENpppD <br /> ///❑MONITORING '''''')) �) //�� GROUT 8 PU I N �y FpE�STAL8YDWLLER:�'w ❑No S. <br /> APPROX.DEPTH c7, (�0 L IrQ Cj ESTTEER B0 XJCT0 VE PIPE RN �r S,r <br /> PROPOSED CON{TAUCT70MMMLLINO METHOD: MUD ROTARY_AIR ROT 1T/TIi.LT 11!E� / a /j1,�nji�"- ftou _OTHER <br /> wor <br /> I HPtFBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOTR LL BE DONE kAc-t_vro�"cam ypT[EI�/J7? G1��C��{Ff{Y ORDIHANCEe,STATE LAWS,ANO RULES'AN <br /> REGULATIONS OF THE CAN JOAQUIN COUNTY,HOME OWNER OR LICENCED AGENT'dJ1).(''���AT 9 THE E9q, WIND%1�7 E ��/{�J)LH(F1T{{�IL(I TNR INANCES,STANCE E 111.AD RUL WMICD <br /> THIS PERMFT 16 ISSUED,I SHALL NOT EMPLOY PERSONS SU&JECT TO WORKMAN'{COMIEl!{A7�L F CA4�D I��OON�Y'iUBJH GO A SUB CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY TWAT IN THE PERFORMANCE OF THE WORK FOR IMIICM THIS PERMR IS ISSUED.I SHALL EMPLOY ECT TO WORgA AN'{COMPETI{ATOM LAWS OF <br /> CAUFORMA-' T E A/I ICCAANT MWT C/U.1/,7/}HOUR{Ifi-MIN�ANCE FOR ALL REQUIRED IN{PECT110"AT 12"1♦p J{2!. COMFTETE DRAWINO AT LOWER AREA PROVIDED. <br /> (VOVVl TIthY7r�/Yl <br /> bae <br /> PLOT PLAN ID—I.S¢M.I Sul• <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A- LOCATION OF EIOUBE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> Z. OUITUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYBTEJ,W, <br /> ]. DIMENSIONED OUTUNF.S AND LOCATION OF ALL EXISTING AND PROPOSED S, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY RT.- <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DPJVEWAYS,AND WALKS, 011 THE PIOTT:RTY OR ADJOINING FTK7FERTV. <br /> reuJ I <br /> aAaslla� a` ) 0� i <br /> G <br /> .. . <br /> 71 <br /> AAAA.:. <br /> S p� <br /> AYME N <br /> DEPARTMENT ME ONLY ENVIROWOENTA!.,HEATH D!V!S!0N <br /> APPFa.tlrn ACerot.d BY • G.te_�_L'�(f�y� A— <br /> O.att IMP—I-BY DFL. Pump In.pec/lon BY b.l. <br /> Datnct:on Imp.ollon BT <br /> D— <br /> All Co-nm.m.: <br /> ACC OUN7ING ONLY; MOF /J O:y n np. <br /> F />7 V�� <br /> PE CODES FLE INFO AMOUNT REMITT[D EC KAFN RECDVED CY DATE PEW.OT7"ERVN;E REQUEST NUTABEq INVOICE <br /> q3� -� a� o <br /> q3� n <br /> 44b <br />