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fihN#LICATION FOR WEILIPUMP PERMIT <br /> UUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH ITIVISION <br /> P.O. BOK 386E 304 EAST WEBER AVENUE, SMCKTON, CA 95201-M <br /> 1209? 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete In Trlplk4191 <br /> APPLICATION IR HERE BY MADE TO THE FAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DFSCRIBFO.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1 1 1 F I AND TIIE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HFALTII SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADDRESemn APNE S. /tjlC( YY�'`/Sd-)-7--5'7)' _ Clrr PARnCEL/SIZE/AITII ,Q <br /> OWNER'S NAMElTC Ij l$V, �d ADDRERB��dD JSP '1� ;/ -,s/ 7 `j' PHONE N <br /> CONTRACTOR gf,-PO 144ese eG,vi/'�'t'1/►.* �^L, 7-/.T^tC AnnnEBB 93'v�m <br /> - - - .- +�+�t.o yhavucE �r h.2 rHGNF E S 6�Qa7�� <br /> OUR CONTRACTOR ADDRESS _ LICE PHONE E <br /> TYPE OF WELLMUMP: ❑ NFW WELL ❑ RFN ACEMFNT WELL ❑ MONrT OMNO WEI1.E _ ❑ OTHER <br /> ❑ INSTAILATION ❑ WELL SVRTEM REPAIR ❑ CROBS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL M ,/ <br /> (TYPE OF PUMP) <br /> 11Ne 11Repelr I1.PDEPT 11 PUMP SET FT. FIRST WATER LEVEL O <br /> ❑ OUT or SEnVICF WELL ❑ GFOMIYSICM.WELL E BOIL BORING p <br /> ❑DES T Rt1CITON: -� <br /> INTENDED USE TYPE OF WELL - CON@TRUCTIOli epEOIFICATIOFI@ A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM CIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO__/___ � p <br /> ❑ DOMERTfC/PR1VATF UnnAVIELPAcK1912F TYPE OF CASINGISTEELIPVC_� _ DIA.OF WELL CASINO <br /> ❑ 1'UBLIC/MUNICIPAI, ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION _ R <br /> I❑y IA <br /> IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY O �Ar a GROUT BRAND NAME rT F <br /> Ea MONITORING / GROUT SEAL PUMPED: ❑Yee IANa CONCnEIE PEDFBIAL BY DRILLER:❑YM ®Ne 5 <br /> APPROX.DEPTH LOCKING CHESTER 80X/870 VE PIPE S <br /> PROPOSED CONSTRUCTIONMMLUNO METHOD: M11D nOTARY AIR ROTARY AI1GEn CABLE OTHER 21 a <br /> I lLEOFRV CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE IAWA.AND RULES AND <br /> FIFOUTATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TIRE FOLLOWING: '1 CERTIFY THAT M TIIE PERFORMANCE OF THE WORK FOR WIICII <br /> TIIB PERMIT IS ISSUED,i 81IAL1.NOT EMPLOY PERSONS SUBJECT TO WORKMAN'@ COMPENRAITON LAWS OF CALIFORNIA.- CONTRACTOR'8 HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT 1N THE PERFORMANCE OF 111E WORK FOR W111Ctt TIIIS PERMIT 18 IBSUFD.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' TIIE P;4T MUST 24 HOUR@ IN ARVANcE F R ALL REOUIRED INSPECTION6 AT f2001440-U23. COMPLETE ORAWINO AT LOWER AREA PROVIDED. <br /> ' <br /> Slgned X Thle O� -Sell/ -IL'j <br /> MOT PLAN 1Drwv to Bcefnl Bc•In�'1e_ yv <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING TIIE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF TIIE PROPERTY,GIVING DIMENSIONS AND Nor"11 DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMFNSIONFO OUTLINES AND LOCATION OF ALL FX18TINO AND PROPOSED E. LOCATION OF WEILS WNIIIN RADIUS OF ONE HUNORED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,URVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY, <br /> SPPi QT rr G Q�S . <br /> ® sem <br /> / d <br /> �✓Ar7'M at LOGS <br /> 1 <br /> UEPAMTMENT USE ONLY /yam J AR/ <br /> Grout 1,4poctlen BY_, .,, _-_ 7r.rw - ......__P,. P ln•P^r+71nr.Ry - _ Uel.___-___ <br /> Dwetr7.:tlen lrxPY tl,r,r no —__ _ - Dole <br /> CnmrPr.rt-: <br /> fACCbVN11Nq ONLY: -_-- f hIDR FACE <br /> PE COOPS FFF.INTO AMOUNT REMIT T F.D CIIy7-K/��7,Aetf RtCE1VF11 RY DATF PFTW ITI@T"VICE REORIENT Nl1MItFR�- INV0fCE- <br /> �.01 <br /> Pub.Health Serv.-Pnviro.173(3/96) <br />