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r-►,. APPLICATION FOR WELLIPUMP PERMIT <br /> r �,;+N JOAauIN COUNTY PUBLIC HEALTH SER1114-1 <br /> ENVIRONMENTAL HEALTH DIYI II611 <br /> P.O. BOX 888t 904'EAST WEBER AVENUE, SPOCMN,CA 95201.988 <br /> (209) UB-3420 <br /> NOR-11101DARE PERMIT PlRE3 I19AN FROIII?IQ IE IlEil <br /> APPLICATION 18 HERE BY MADE TO THE BAN JOAOUfN COUNTY FQR A PERMIT TO CONSTMUCT�AND"MALL THE WORK DESCRIBED-THIS APPLICATION 18 MADE IN COMPLIANCE VM14 SAN <br /> JOAOIHN COUNTY DEVELOPTAENT TITLE.CHAPTER 9-1116.2 AND THE STANDARDS OF SAN JOAOUIN COUNTY pUBL1C HEALTIf SERVICES,ENVIRONMENTAL HEALTH atVIt110N, rN <br /> it <br /> JOB ADOREBD/OR APNI k <br /> t CITY PARCEL SL-WAPN>t,_-r�7�� <br /> OWNERTI NAME <br /> XANC ADDRESS <br /> CDHrR4eTaR ; PHONE+!v�"�4a8-1�'S� <br /> ADDREOS S'�- LOCI-_ Isol PHONE I�7�d���3 <br /> E OUR CONTRACTOR <br /> Atomwx <br /> PHONE/,IVA IC <br /> f 2 w WELLIPUMP: 0 NEW WELL D REPLACEMENT WE1l, © MDNITORnvG WELL* I ❑OTHER <br />[ D INSTALLATION - DWELL 11/BTEM REPAIR D CRQSq-COMQCT REPAIR I]VAPOR EXTRACYIDN WELL I <br /> 13 J <br /> ITWW OF PIAIPI New❑pApab Hp -"`� DEPTH PUMP Wt FT. FIRST WATER LEVEL <br /> TI� 6 <br /> D <br /> OUT-CF-SERVICE WELL ❑aEOPHYBICAL WELL I �ij SOn.DORRN! <br /> D DESTRUCTION: <br /> MTOF <br /> D INBUSTRIAL D OPEN BOTTOM {' A <br /> IIA.DF WELL EXCAVATION I Of/1 Of CONDUCTOR CASING D <br /> D DaMEeTIimyATE D aRAVE <br /> L PACKlSIZE - <br /> F-L TYPE OF CASING►STEELJPVC i1 DIA.OF WELL CAtTMKi O <br /> I.J Pl BwiM <br /> UNK iPAl ❑DRFVEN MOTH aF OMUT SEAL SPECIFICATION <br /> D IRRIGATION/AG OI HER _L^ y1 ,^� E <br /> �TC.VK 6��SEAL INSTALLED BY C/I G r if GROUT BRAND NAME <br /> ❑ MwaroRSla 4 M GROUT SEAL PUMPED:D Y« D No CONCRETE PEDESTAL Br <br /> ``$ `t�"" oRILLER:©Yoo Ow. <br /> s <br /> APPROX.D>FJ'TH LOCKING CHEWER SOXIBTOVE ire_ <br /> S <br /> PRIWOSW CONMTT111CToMDIEUM METHOO; MUD ROTARY AIR ROTARY AUGER l CABLE OTHER <br /> t ii <br /> 1 HUM CERTIFY THAT 1 HAVE PREPARED TIME APPUCAMN AND THAT THE W014K WILL SE DOME(N ACCORDANCE WITH SAN JOAOUtN COUNTY ORDIk/1NCEe STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOA(UIN COUNTY. HOME OWNER OR 110EN8£D AGENT'S SIONATLIm CERMMS THE FOLLaYY W!'1 t-UMFV THAT>N THE PERFORMANCE OF TH1 WORK FOR WHICk <br /> THIS PERMIT IS 18GM,i SMALL NOT EMPLOY PERSONS SUBJECT TO WORM"'*COMPEN8AlMN LAWS OF CALIFORNIA CaNTR1 uawe HnNa OR GUBtONTRtACTRtfl SISNATWE CEITTIFIEB <br /> THE FOLLOIMNG: -1 CERTMY THAT IN THE PERFORMANCE OF THE WORK FOR WIMCN TMS PERMR M 18SUED,1 SHAlL EMPLOYIPERSONS SUBJECT T6 NrNNgtMAN'S COMlpNATUREd&ATION LAWS OF <br /> CALIFORMlL- TiIE ANT MUST .Z4 URB Mil ADVANCE FOR ALL REGUMW DWOCTI0111 AT Heel 4n44E2. COMPLETE DRAWMM AT LOWER AREA pMVIaEO1.[y t� <br /> air+.+X Tale � <br /> PLOT PLAN tDrew to Salol U" 'to <br /> t. NAMES OF 6 OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DIWOOAL SYSTEM OR PROPOSED <br /> t. OUTLIVE OF THE PIIOPEIRY,DIVING DIMENSIONS AND M AN DIRECTION. !1 EXPAUMM OF SEWAGE DNFOSAL eywmme. 1 <br /> a. DDAEN U NEO OWLINCLW ES AND LOCATION OF ALL EXISTING AND PROPOSED 1. LOCATION OF WELLS VVn"lN RADR)9 OF ONE HUNDRED FIFTY FT. <br /> BTRUCTiRRES,INCLUDMIO t CIVERI AREAS SUCH IIB PATIOS,DRIVEVYAYB,AND WALKS. ON TKPADPEIWY OR ADJOINING PROPERTY. <br /> i ... <br /> �1 <br /> DWART'MENT UNE ONLY <br /> AMft*t%n AaaapW BT ,F <br /> J� Det- Z. Are- �` <br /> Grout Irrp-otbn ST yl.4 CAh _Dna z3 pump Inspeatlan By j: <br /> h bate <br /> Daftrcetlon Mtapeotlan <br /> Oat- <br /> Cemrnorta: <br /> v <br /> Accumi NG ONLY: AID# ij <br /> FACT � <br /> PICOM FEE INFO AMOUNT I19"ITTED CHECKIICASH RECOVED 1Y DATE I1', <br /> g PLRMIT14"W CE REQUEST NURSER fNVOME <br /> ;.CIO L ,pv ,Z�g^ to tr <br />