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APPLICATION FOR WELLIPUMP PERMIT �_� � '"' JOAOUIN COUNTY PUBLIC HEALTH SERVICES ' PAYMENT ENVIRONMENTAL HEALTH DIVISION RECEIVED P.O. BOX 388, 304 EAST WEBER AVENUE~ STOCKmK CA wmol 88 Q091APR 0 5 1996 NOW-REFQMQA6lI PERMIT EXPIRES Z YEAR FRAM DATE ISSUED j SAN Jo,,_4UIN C;QUNTYPUB IC HEALTH SERV+C.CS I ENVlRO I. I�LfA}ICI�tVRFi WW - CATION 18 MERE BY MACE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WORK DESCRIBED.THIS APPLICATION K)N 19 IS APPLICATION MADE[ -,o iQU1N COUNTY DEVELOPMENT TRL£.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVMONMEINTAL HEALTH DIVISION. ,706 ADDRESSNOR APNO 26 SV N• T-NEx MLA• CITY ��`��/ PARCEL SEMAPNS 7vVNE"NAME ADDRESS - PHONE Y :ONrRACTOR l'I�c1t�t ��v+�o�w�a-�.� {IGIa••� �►.c.� ADDRESS �SUo W. �.l C4v�•y�w 14ve3a.Jn..;ev4 r+IaNE %oS ;� V h��LK �y�. ?< law S1 i��o%4i W% :u�CONTRACTOR W � R. ADDRESS ,�r LLCs 6 b PHONE s-[Q>/ll`4-Vii 'TE OF WELIJI+UMP: ❑ NEW"MIL. - D REPLACEMENT WELL ❑ NIONITORINO WELL/ .: ❑ OTHER - - ❑ M&TALIJITION ❑ WELL SYSTEM REPAIR ❑ CROSSCONli REPAIR ❑V;mn unwwmm WELL! J ❑N.©pwi H.P. DEPTH PUMP SET FT: , .: FRIT WATER LEVEL 0 YPE OF PUMP! ❑ aur-0ER F-SVICE L I WELL ❑ GEOPHYSICAL WEL [� BOIL 90111 i° .. ' B DESTRUCTION: W !TENDED USE TYPEOF WELL !-�1/� CONSTRUCTION ioECCIRCATIONS 1, A O 7 INDUSTRIAL ❑OPEN BOTTOM l'J DIA.OF WELL EXCAVATION #I DIA.OF CONDUCTOR CASINO 0 3 r AOMEurnmimVATE ❑GRAVEL PACKMIZE TYPE OF CASINGISTEEL/PYC GIRL OF WELL CASING .PUSLIClMt1NICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATRON q -�7 MOGATIONIAG ❑OWNER GROUT SEAL INSTALLED BY GROUT BRAND NAME E .F�MONITORING aRouT SEN.WIPED: ❑Y« ❑N.:i CONCRETE PEDESTAL BY DRILLEIC❑Yw ❑N. s 191 DETTN o LDG%INO CHESTER SOK/BTOVE PIPE S aOPOfED CONSTRUGTIONIORBLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Ao Lli GAJOW 'E"IEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND AIM ATIONS OF THE SAH JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTTIRES THE POLLOWli•1 CERTIFY THAT IN THE PEF"AMIA E OF THE WORK FOR WHICH %M Pi IS ISSUED,1 SHAL L NOT EMPLOY PERSONS GUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOFWTA.• CONTRACTOR'S HIRINO OR*us-:ONTRACTING SIGNATURE CERTIFIES IE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS I El7M1'T IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF MJFOMAX" ANT MUST CALL"URS IN ADVANCE FOR ALL REOIARm INSPECTIONS AT"144110-2422. COMPLETE DRAWING AT LOUVER AREA PROVIDED. X_ Q• �- 0�--- , r2.G. TIS._ &v. C«j,If w J 1Zn�_ Cil. PLOT MANN IDr.w t.So"Gad. •m -��' NAMES OF STREETS OR ROADS HEAPEST TO OR SOUNDING THE PROPERTY. - 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED . OUTLINE OF THE PROPERTY.ari DIMENSIONS AND NORTH DIRECTRON. - ""'•';""� EXPANSION Of SEWAGE DISPOSAL SYSTEMS. DIMENSIONED OUTLINES AND LOCATION OF ALL EXl9nNG AND PROPOSED c. S. LOCATION OF WELLS WITHM RADIUS OF ONE HUNORED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WALKS. 'I ON THE PROPERTY OR ADJOINING PROP TTY. .... .............:.................. ........--...- .- - - ......... ...... :. ..........:.............. .. .- .. - .......................................... .. .. .. .. _ . d ...... .. . . . i :... ..:...... .... .... ......................... .. .......... ....... r..-........ .. .. .. . . ................................ ............. ;....-....-.. . .. .. .. ......... ........:...................... ....:.. .... .-...:: . � 1 DEPARTMENT USE ONLY �y .,&fkwnlon AnoWed BY- Dos Ann ,Gut Irspaetlpn BY D.t. "T r(�(tD P r.hsv..8mt B1 - 'coi O 110 1 am -trucdm Ink.@ml.n Sy _ 'Dow :�.,..nt. £ St3 y IV ACCOUNTING ONLY: AIDS FACS . FE CODES FEE INFO AMOUNT RSYSTTE.D CHECK.m"H RECEIVED NY DATE P9M4TIZE RVICB REOUEST NUMSER INVOICE SSSS z o� / O ns