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APPLICATION FOR WELL/PUMP PERMI <br /> SAWQUIN COUNTY PUBLIC HEALTH SESy�o.. 5� <br /> SION <br /> 304 EAST WEBER AV6NUENVIRONMENTAL GSTOCKTO95202 <br /> ALTH IN, CA �- <br /> 20s 4 33 <br /> PION-REFUMDpRLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> OR <br /> ICOM <br /> 1611 <br /> APPLICATION N HERE EL MADE TO THE SAN JOAOUIN COUNTY FOR A PEgMIT TO CONSTRUCTT In T,IpIkSHII LI THE WOW DESCRIBED.TI113 APPLICATION 16 MgpD IN COMPLIANCE <br /> JOADUIN COON"DEVELOPMENT <br /> THIf�CHAPTEq 8-1115,3 ANO THE STANOAROS OF 6AN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADDRES6/OR APNI 7 6 ^;A, <br /> N. NCE WITH SAN <br /> / !+`� j� CITY USAO Cfc 1� ,e)g/-- <br /> 61 <br /> /R D g Dr Cioa-.tifv Dr PARCEL BIZF/APNI Vy� Q <br /> c 1 ,yrR e.�au-nf FCsDt:Di /goo Po well SY._ee}, /a F7,-. @�V <br /> c.f nr DDRE6e Fw,Pr, ��� a 9u6oR-/877 <br /> PHONE <br /> AOpHEeB <br /> SUR COMMCTOR 30 E q1' O0O) Dam m' <br /> = PHONE I, <br /> ApDREBHJSze L, � 1 ('l39c77 y�/'H7z uc. / <br /> MM � PHONEF 707-8,73 <br /> TYPE OF WELL"I ILY NEW WELL ❑ REPLACEMEM WELL <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR MONITORING WELL A ® OTHER <br /> U- 0 ❑N.DR«eL H.P. CRO88-CONNECT REPAIR r/ON <br /> q VAPOR EXTRACTION WELL/ <br /> (TYPE OF PIMPI DEPTH PUMP SET 8O FT. ✓ <br /> FIRST WATER LEVEL__ <br /> OUT-0F SERVICE WELL ❑ GEOPHYSICAL WELL. ff�� O <br /> El DESTRUCTION; ''--L SOIL ROBING <br /> B <br /> INTENDED USE TYPE OF WELL <br /> 1:1 ❑OP <br /> INDUSTRIAL CONSTRUCTIONCAVATICATIGNB <br /> -1 YUEN BOTTOM GIA.OF WELL EXCAVATION A <br /> 1J DOMESTICRVATE ®GRAVEL PACK/SIZE DIA.OF CONDUCTORCASINO A)/ D <br /> 1] MBUCIMUNK,I 11 DRIVEN 6 TYPE OF CASING/STEELJPVC .k(r'/C DIA.OF WELL CASINO <br /> DEPTH OF GROUT SEAL ?e) I <br /> IRRIGATION/AG �/ ❑OTHER GROUT SEAL INSTALLEDE+T- SPECIFICATION <br /> APR ONITORNG��ATr/yC)Cy'� BY y.J /tJpQ n P R <br /> APPROX.DEPTH <br /> f GROUT SEAL PUMPED: ® GROUT BRAND NAME <br /> 90Ys ❑Ne CONCHETE PEDESTAL BY DRLLER:®Yee ❑He S <br /> PROPOSED <br /> CONSTRVCTIONIDItllUNO METHOD; MUD 110TAf1Y LOCKING CHESTER BOX/STOVE PPE 1/ s <br /> AIR ROTARY AUGER CABLES <br /> OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS AI'Pl1CATIOIII ANO TNAT THE WOR(WILL BE GONE IN ACCORDANCE WITH BAN JOAOUIN COVMY ORDINANCES,-TATE IAWB,AND RULES AND <br /> REGULATIONS OF THE SAN ALL NOT COUNTY, HOME OWNER an LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT RJ THE FERTORMANCE OF THE WORT FOR WHICH <br /> THIS PERMIT IS ISSUED,I BIIALL NOT EM0.0V MR ME <br /> SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFOgNfAI COMMCTOR'8 HIRING HE PERFORM N C OF SIGNATURE CERTIFIES <br /> THE FOLLOWING:p; •I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY AkCTOW HRING TO UB CONTRACTING <br /> NT RAC COMPENSATION LAWS OF <br /> CALIFORNIA,• THE APPLICANT MUS UIO IN ADVANCE FOR ALL REQUIRED INSPECTION.AT UOSI A60 A22. COMPLETE DRAWING AT LOWER AREA PRONDEO, <br /> 61anM% V-! <br /> TNI..s1LLL /�Q r- <br /> Dae��/711r� <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING PLOT�N <br /> Z. OUTLINE PROPERTY. -cele OUTLINE OF THE fNOFEgry,GIVING DIMENSIONS AND NORTH DIRECTION. 4, LOCATION OF HOUSE SEWAGE OISMSA <br /> G. DIMENSIONED OUTLINES AND LOCAL N OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. OR PRipPOSED <br /> STRUCTURES,INCLUDING COVERED AREA 'VC <br /> H AS PATIOS,DRIVEWAYS,AND WALKS S. LOCATION OF WELLS WITMN RADIUS OF ONE HUNCHED FIFTY FT, <br /> ON THE PROPERTY OR ADJOINING <br /> pppp � <br /> PROPERTY. <br /> EN <br /> "! F}p )q <br /> FEB 2 3 1998 <br /> L_ SAh il)AOUIN <br /> PC <br /> UBLJC GUN7 I <br /> :SSSS. -HEACJH SFS/Ir - <br /> ._ <br /> DEPARTMENT USE ONLY � <br /> APaicalen Aec«ted By <br /> G.eu IrwP«Ilon By D.I. S-��(� Are. O6 / <br /> Da° Pune Inep«tlen By <br /> D.wlnrllen Imp«Ilpn By —y— Dae <br /> G 11w?)q (�CG.aad QDL4.t��1( <br /> ACCOUNTING ONLY: AIRF 9 <br /> FACE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKF/CASH RECEIVED BY DATE PEIIMITIIFgVICE REGIA:eT NUMBER INVOICE <br /> 2 0 00 o G <br /> ZPubZ.Z3 r8 5 # 01-662- <br /> Pub. <br /> .Health Saw.-Enviro.173(1/97) <br />