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APPLICATION FOR WELUPUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION QSZb2. <br />304 FAST WEBER AVENUE. STOCKMK CA <br />QQ9' as -u2° 3rdAz°r ORIGINAL' <br />1109-AFFUNDABLE PERMIT <br />1 <br />APPLICATION IS HERE BY MADE TO THE SAW JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER S-1 115.3 AND THE STANDARDS OF, SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVMgNMENTAL HEALTH DIVISION. <br />-EjJOE ADD --3810?, ACITY <br />7T7J17 /Jl'� <br />ADD--3810?,PN/ PAIIC]ELLrSIMAPNI <br />OWNER'S NAME ' A AD01tESi ic%Zls�S:Wm.�„>u- i -K`. 1/h vC'. V �i•/ L( PHONE I;�-TT l r 1 i <br />–[L <br />CONTRACTOR ` 1'�- l f_' � i rte... ADOrtsS -�f"-,.A J �. . r A. 4 `f ,{'sem UCJ_� PHONE � G ��1919 <br />SUB CONTRACTOR ISf'r Y�� N ADDRESS` '7�TTdJt �[.c�t f A` LC/ lY , PI10ME I �l . <br />TYPE OF WELLIPUMP: D'NEW WELL ❑ REPL.Atcmwr WELL MONrroraNG WELL / ! �U•t+MV OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-cY)NNECT REPAIR 'Sl�� VAPOR EXTRACTION WELL I ✓ <br />❑ N.w ❑ P.O.* H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O .. <br />(TYPE OF PUMP) <br />❑ OUT -0E -SERVICE MIEN ❑ GEOPHYSICAL WELL I ❑ SOIL NNW40 8 <br />❑ DESTRUCTION <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SP0::IRCATIONS <br />d <br />A <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />DIA. OF WELL EXCAVATION NA. OF CONDUCTOR CASINO � <br />D - <br />❑ DOME3TICRRNVATE <br />❑ GRAVEL PACKISQE <br />TYPE OF CASINGMT-EELJPVCS : `L�' V� DIA. OF WELL CASING <br />D <br />❑ PVMJCJMUNICIPAL <br />❑ DRIVEN <br />DEPTH OF G11OUT SEALn ( SPECIFICATION <br />R <br />❑ IRRIOATIONIAC <br />D OTHER <br />GROUT SEAL PCCTALUM BY ! A ✓• GROUT GRAND NAME <br />£ <br />a'M10NrmR,w, _ r, _ _ WOUT SEAL PVMPEo- '--' '. ❑ Ide CONCRETE PEDESTAL BY DwLLEk- ❑ Y- ❑ Ne s <br />AVPROIC DOTH as T ` IG d�- , ' ]----*> LOCKING CHESTER SOXIUTOVE RPE s <br />PROPOSED CONSTRIICTOWDMLLMO METHOD: MUD ROTARY ARS ROTARY AUGER CABLE OTHER <br />1 HEREBY CERTIFY THAT 1 HAVE PREPARED TMS APPLICATION AND THAT THE WORK WILL 6E DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTS' ORDINANCES. STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIRET THE FOLLOWING: 'I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY PERSONS StMUECT TO WORq+IAN'S COMPINZATON LAWS OF CALIFOMAA-' CONTRACTOR'S HWWM OR SUR-COHTRACTWO WGNATUIE CERTIFIES <br />THE FOLLOWING: ' I CERTIFY IHAT IN THE PERFORMANCE OF THE WDRK FOR WHICH THIS PERMIT IS ISSUED. i SHALL EMPLOY PERSONf SLI6JECT TO WORXMAK'S COMPENSATION LAWS OF r A <br />vJ CALIFORNI.t' t�i C URS IN ADVANCE POR Am RfOUMLED (NSC-nop"AT me) AmJPL <br />bn.421. COMPLETE DIMWMO AT LAWEIL AREA PP"OVIDED. /yy V 2\ <br />I,C ` Sd X T.agL( I I, i / . <br />PLOT PLAN D— m 6--W S.M. ' t. <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY, GNINO LNMENSKINS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND RIOPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HONORED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS. DFWVEWAYE. AND WALKS. ON THE PROPERTY OR AD"RAM PROPERTY. <br />A,,Ib–oon A—m d By <br />O.out Irwo.ctl«i By <br />O..tn.ctbn <br />ACCOLOMMO ONLY: I ADZ <br />" CODES ( FEE INFO I AMOUNT RVAITTRN <br />DEPARTMENT USE ONLY 9 9 <br />D*q. q- a3 <br />D.t. PR m knv.ctlon By <br />1 <br />FACT <br />CHECKNICASH I RECEIVED VY I DATE <br />S��v�01 <br />Dat. <br />-_.I .INVOICE <br />