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APPLICATION FOR WELUPUMP PERMIT 'j" 1` <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIPAS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Nwop.0.BOX 388,304 EAST WEBER AVENUE,STOCK,CA 95201388 <br /> (2091461-3420 <br /> (Complete In NON•IIEFUNOABLE PERMIT EXPIAEJ 1 YEAH iIIOM LATE Il3UE0 <br /> tal <br /> APPLICATION If/IIF[By MADE TO THE BAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DEsCRSBED,THIS APPLICATION le MADE N COMPLIANCE WIT"SAN <br /> JOAOUN COUNTY OEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUN COUNTY PUBLIC HEALTH SEm4CEe.ENVIRONMENTAL WALT" <br /> OM,064 <br /> JOB ADDRESSIOR API/ YJ.ry. S4 R ToaviA 54CRY �Q�<�Oh ^-� <br /> Rot; G ) / ,1' PARCEL SQUAM.�(50"7(I So"/.Sry�o%, <br /> O S �Ilicpch 154/ w„ ADDRESS /-I 70 GolllL.]�1� tj�• .44�"WECONCo.: M i 4Ch 11 Dr;I 1 i ADDREeeBUS <br /> ADDRESS LK:I PHONE P <br /> TYPE OF WEI I A .. ❑NEW WELL ❑REPLACEMENT WELL MONITORING WELL/ W <br /> ❑INSTALLATION ❑WELL syeTEM REPAIn ❑cnosecONNECT REPAIR 13 OTHER <br /> ❑VAPOR EXTRACTION WELL/ J <br /> ❑N—❑RAW H.P. DEPTH PUMP SET�_R. <br /> (TYPE OF PUMP FIRST <br /> WATER LEVEL G <br /> ❑1-OUTCF-S1ERVICE WELL ❑GEOPHYSICAL WELL 1. <br /> DERRt/cT10M 4r I �01'CLJ Sf.quAp-S 'b 50 5af . 1 ;lpr•� 1u/ Hlla�6h1 1•.� yIG -f— {4o5O 5jS. <br /> e rRl._ <br /> INTENDED US[ TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑NoUBTISAI / A <br /> ❑OPEN eOROM dA.Of WELL EXCAVATION DIA.OF CONDUCTOR CABNG <br /> ❑DOMESM/PRSVATE []GRAVEL PACKMZE D <br /> TYPE OF CAMMIGMTEEUPvc 1^DV(I dA.OF WELL CASING D <br /> ❑PUBUC/MUMCIPAL ❑DISVEN DEPTH OF GROUT SEAL 1"N SO-A4 C SPECIFICATION <br /> ❑SIISOATON/AO ❑OTHER GROUT SEAL INSTALLED BY P, I— I Pte✓ OROVT BRAND NAME R <br /> ❑ <br /> MONITORING E <br /> GROUT SEAL PUMPED:v Yr ❑N. CONCRETE PEDESTAL BY ORRLEFL❑Yr ❑N. s <br /> APPROX.DEPTH SO' LOCKING,CHFSTEn SOX/STOVE PINE <br /> S <br /> PROPOSED COMSTMlCT10N/DISLUNO METHOD- MUp 110TAR1' AM nOTAl1Y AUOEIL X CASLE OTHER <br /> 1 HE1Esy CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS Of THE SAN JOAOURN COUNTY.HOME OWNER On LICENSED AOENT'S VONATURE CERTIFIES THE roLLOWNO:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WINCH <br /> THIS PERMIT M ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNI&.COW CTOR'B MIRING OR SUB-CONTRACTNG SIONATVRE CERTNIE6 <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH TMS PERMIT Is ISSUED,1 SHALL EMPLOY PERBONS SUBJECt TO WQRKMAR'S COMPENSATION LAWS OF <br /> CALIFORNIA.' Tll/[��/}��,►MP�,LUC�AffT MUST CALL 34 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1"014SS.S42S.COMPLETE DRAW 40 AT LOWER AREA PROVIDED. <br /> SISrw/X— '/"I• ��� TIL.- P-0 i WT"7'W",4� D«. <br /> ry� <br /> PLOT PLAN IDtw«t.Sed.1 9w. 1 a. •1/ <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE POPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PIOPpBEO <br /> 2.OUTLINE OF THE PROPERLY,GIVING oIMENSONB AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 3.DIMENSIONED OUTUNF.S AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS E IIP SAL VYOFTONE HUNDRED FIFTY R. <br /> STRVCTVIIES,INCLUDING COVERED AREAS SUCH M PATIOS,DRIVEWAYS,AND WAXS. ON THE ONO F WE LS ADJOINING RADIUS <br /> PROPERTY. <br /> SEE �-f1,}Ch4eo PtbT P('4'j ; .. :. <br /> . . n•n10 `ul � <br /> CoNST,)C.T[oe1 f 6141 L . <br /> 1 <br /> DEPARTMENT US[ONLY /J� /r/�' 2 <br /> APPD..t1.n A..AM.d BY 0.. ✓•2/ / Mr <br /> a.Mll MP..tbn eT - D«. Punt 1--ti-BT O«. <br /> Ogot tl.n FwP..tl.n B <br /> C«.,mw,t.: Pno ALS V334 to CLrl-eunq,C IVxSpuft0" @feast two ww'". da�S PYILOf bstartdzfC <br /> ACCOtNTNO ONLY: Alp/ FAC/ <br /> R coots FEE INFO AMOUNT REMITTED CHECKOICASH RECEIVED SY tDATI Pff"T/sORwa REOUEJT Nto"Eft "mica <br /> 3¢✓b2 (oa t)5053(, �- O 1 2(o I <br />