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APPLICATION FOR WELLIPUMP PERMIT <br /> .s,.,,3AN JOAaUIN COUNTY PUBLIC HEALTH SERVII, ,Oqo� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 S AST WEBER AVENUE, STOCK—M9, CA SS201-Ma <br /> (20) 2463-3420 2 1059e <br /> MON-MFUNDARE ?--;;i;T EXPIRES I YEA; F30M 1,17--!Sit-Itl <br /> A r'rLfCATION IS I IE PC BY MACE TO THE-,APO JOAGUIIt t:DIlIIr,,Tnn A FFFTMIT %Pinf(In MS TAIL T)4F','JC?— 7-C-I RED. TI If S IS J"[jtjNrQMPtIANCE WrT 11 SAN <br /> JOAQUIN COUNTY CE%TLOPMCNT TrTL&CHAPTER 9-1;I rl.3 Atin Ts,rt STAP.i.Arn.4 0;!-1AN jOAOIIIN rrjjjNTY 1`4)PIAC ?!,*�FIIVICIS.F.NV!PntfA.0FlffAI.14FAI-TH DIVISION. <br /> JOB AOOPESSIOR APNO 7342 air,, -2 ISACEL 51ZEIA".1,11 <br /> -�'& <br /> owwo-sNAME MCI 5 AnnF.z, -1 7-3-q PHONES ylv To-moi LIO IO <br /> CONTRACTOR L L r- VL C_ An,)rFrq ;,HoNOC Or Zz-'j-53 14�Lj <br /> SUB CONTRACTOR J? r L.kv AnnFFss -pa 6ck�,Lq,&4'13�4, <br /> TYPE OF WEILUIPUMP! 0 NEW`HELL [I FWT4,NCFMFPIT WELL Cl 11101111`nPWIIWFIL 1 0 OTHER <br /> Cl INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION'WELL 0 <br /> 0 New 0 P..k H.P. OEPT"PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PV MPI Cl our.or.SERVICE WELL 0 (IC0PIIYS:rA(.WELL A tGt .431L a0RI"Q a <br /> Cl DESTRUCTION! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION{ A <br /> 0 INDUSTRIAL Cl opem so rrom DIA.OF WELL EXCAVATION OIA.OF CONOUC TOR CASING 0 <br /> 0 DOMEgTICIPRIVATE 0 GRAVEL PACK/SIZE_ Tyrf OF CASINGISTFELIM/1- OIA.Of WELL CASING 0 <br /> 0 PUBLIC,-MUNICIPAL 1:1 Dnpfm DEPTH OF GROUT SEAL SMCIFICATICH R <br /> 0 IRRIGATION/AG G—OTMER �l yt-��C. GROUT SEAL INSTALLED 3Y G-POU'r BRAND NAME OF <br /> MONITORING GROUT SEAL PI)MIVOt ❑ O <br /> Y_ N. CONCRETE PEDESTAL OYDRILLER:OY- CIN. <br /> APPROX.DEPTH c: LOCKING C)-FSTE,i SOXIRIOVE 'IPE s <br /> PROPOSED CONSTRUCTIONADMILLING METHOD! MUD ROTARY AIR ROTARY_AUC'FIR CABLES OTHER /4,,S,,cl A <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE!P4 ACCORDANCE'KITH SAN JOACUIN COUNT/ORDINANCES,STATE LAWS.AND RULES AND <br /> nEGULATIONq OF THE SAN JOACUrN COUNTY. HOME OWNER OR LICENSED AGENT'S 3IGNATUPC CERTIFIES THE F--UO%MNG-'I CERTIFY THAT IN THE PERFORMANCE OF THE V40FK FOR MlIC14 <br /> THIS PERMIT 19 ISSUED.1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAWS C!7PAPSNSATION LAWS OF CALIFORNIA,* COtSTRACTOITS t4IRING OR RUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT:N THE P'SPFOPMANCE OF THE WORK FOn WHIC-4 THIS P-Ftk4rr IS ISSUED.I SHALL-Ik.4P`,OY­T1500ift-UAJFC7 TO WORKMAN'S COMPENSATION LAWS 01: <br /> CAkJF0RNIAt,,7 A:TN;�6 69ANCl FOR ALL ACQUIRED INSIP-ECTIONS AT(2001442ZA22. COM{*FTECPAWING AT LOWER AREA PROVIDED. <br /> IN MCI F4 <br /> Slal.d X c <br /> TOO. COE- H <br /> PLOT PLAN rD,—,.IMW.1 Awm. <br /> 1. NAMES OF STREETS OR ROADS NEARFST TO on BOUNDING T14F PPOPFFITY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2, OtFTIUNF OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EVP^N@IOM OF qeWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTUNF.9 AND LOCATION Of ALL EX19TTHO AND PROPOSED 15. LOCATION OF'APELL9 WfTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALXS. ON THE PROPERTY On AD--OINING PROPERTY. <br /> vvu <br /> DEPARTMENT USE ONLY <br /> AePlknlon A—I"d By <br /> Dam <br /> I—p—do.Sy lm. <br /> U <br /> ACCOUNTING ONLY: I moir I FACT <br /> PC CODEAI I FSE INFO 1 AMOUNT qUAITTZD CIIECXN,'-,Agif i RECEIVED Sv OATIE <br /> -7WITINERVICT 111FOLMST MUININFR INVOICE <br /> Pub.Health Serv.-°nvirc.I 7�X1196) <br />