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APPLICATION FOR WELL►PUMP PERMIT <br /> SAN JDAOIIIN COUNTY PUBLIC IIEALTN SERVICES <br /> ENVIRONMENTAL IIEALTII DIVISION <br /> P.O. 80X 388, 304 EAST WEBEn AVENUE, STOCKTON. CA 9S201_w <br /> (209) 4811.3420 <br /> NON-REFUNdABLE PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED <br /> APPLICATION 19 IIEnE BY MADE TO TIIF SAN JOAOUIN COUNTYFOR A hEnMli TO CONSTRUCT Istel <br /> OANDlR INS, TA1 L T11E WORK DESCnIpF.D.T1119 A <br /> JOAOUIN COUNTY DEVELOPMENT 1nLE.CIIAPTEn B•1119.3 AND TIIE STANOAno9 OF RAN JOAOUIN Co UlTry P111LIC IIEALTN Srn\Acrg.ENVIRONMENTAL 11EALT11 DIVISION. <br /> �f j� PT'LICATION t6 MADE IN COMPLIANCE WITH SARI <br /> JOB AODnE99/On APN/ �W <br /> OWNER'S NAME_ ( PAncFL AIZF/APNI <br /> ADhnFAA ° 3 y� � <br /> CONTRACTOR ( � ���1 � �i1 i7 � R � i'110NE/ <br /> AOORF RR zoO <br /> SUS CONTRACTOR L.JL_S `•� LIC;E Z1� MIONE I� I <br /> / L <br /> ADORERS N`� ` . <br /> LIP_/!' p10NE <br /> TYPE OF VELL/PUMP. ❑ NEW WELL - <br /> RFPACFMEM W£LL ❑ MONITORING WELL <br /> ❑ ❑ OTHER <br /> INSTALLATION <br /> ❑ WELL SYRiEM REPAIR ❑ CROSA-CONNECT REPAIR <br /> ❑❑ VAPOR EXTRACTION WELL IEl /New El flep.lr H.P. DEPTf I RUMP SET <br /> 11 YPE OF PUMP) FT. FIRST WATER LEVEL <br /> O <br /> Ol1T-OT'RCRVICE WELL ❑ OFOPIVSICAI-WELL I r�j/ <br /> w SOIL ROBIN <br /> ❑OE9TRUCTION: y <br /> INTENDED USE TYPE OF WELL _ - <br /> CONSTRUCIION SPECIFICA110NS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL FXCAVATION 2,Z.s ,( , A <br /> ❑ DOME9TIC/PIVATE ❑OnAVEL PACK/SIZE - DIA.or CONDUCTORCASINO <br /> lYl7 OF CARING/RTFTI/PVC D <br /> 11PUBLIC/MUNICIPAL L1 bnIVEN DIA.OF WELL CASINO O <br /> DEPTH OF GROUT REAL F�� _e <br /> SPECIFICATION__ <br /> ❑ 1Rn1OATION/AG ❑OTHETI GnOUT SEAL INRTAII ED By R <br /> ❑ MONITORING i�gdOnOIJT ARAND <br /> /_ GROUT REAL hVMPFD: ❑y.. ❑Nn ER:El Y_ <br /> SND S <br /> APPIO%,DEPTH �(. CONCRETE PEDESTAL By DRILL <br /> LOCKING CHESTER BOX/RTOVE PPE <br /> PROPOSED CONSTRUCTIONIDFUIUNG MET110 D: MUD ROTMVS <br /> AIn ROTARY AUGER CABLE. <br /> oTNFn <br /> I HEREBY CERTIFY THAT 11IAVE PREPARED TWO APPLICATION AND 714AT TIIF WOTK WILL nE DONE IN ACCORDANCE WITH RAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> nEGUlAT10N9 OF TNF SAN JOAOUIN COUNTY, HOMF OWN£n On LICENSED AOFNT'8 SIONATUnE CFRTIFIES THE FOLLOWING:'i CERTIFY THAT IN TIIE PERFORMANCE OF TIIE WonK FOn WIIICII <br /> 71419 PEnMIT 18 IBBUEO,1 SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUTORNIA.- COWAACTOn•B/BRING On SUB-CONTRACTING SIONATURE CEnNrlEB <br /> THE FOLLOWING: '1 CFTRIFY THAT IN TIIE PERFORMANCE Or"IF WORK FOR WIIICII 7111R PERMIT IB ISSUED,i SIIALL EMILOY P111SONA 9URJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAI.IFORNIA,' THE APPLICANT MUST CALL 24"Oung IN ADVANCE FOR ALL nEGU1REb INSPECTIONS AT 12001 4004423, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Blprw.d% ��� /U, Tille T"" <br /> PLOT PLAN Ihr.w t.Se.7.1 Re.i. to <br /> I. NAMES OF ATRFEFS On ROADS NEAREST TO On POUNDING TIIF PIOPRTy <br /> 2. OUTLINE OF TIIE PnOPF.RTY,GIVING OIMFNSIONS AND NOnm DIRECTION. 4, LOCATION OF IIOVRF:SEWAGE DIOtb BAL SYSTEM OR 1'TIO POKED <br /> 3. OIMENSIONED OUTLINFB AND LOCATION OF ALL EXISTING AND PnOPOprb EXPANRION OF SEWAGE DISPOSAL 9YRTFMB. <br /> STnUCTUnEB,INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALK a. S. LOCATION Or WFLL8 WITt11N RAMUR OF ONE HUNOREO r11Ty FT. <br /> ON TIIF PROPERTY On ADJOINING PIOT`F.RTV. <br /> .......... - .. .. .. .. <br /> ........... .... (44 <br /> ...........:................. <br /> DFPMiMFNI USE.ONLY r <br /> APPlle.tlon A...pted Ry lfY` J JL( '1 p <br /> Gre�l Impeetlon By /!hA­ L,v•/ <br /> I --°°„ bae3>/°�hne,P In.nmalen Sy __-�----__ <br /> be.Ir tlen I_peatbn Ay DH• <br /> Com I DO. <br /> 66 3�'r <br /> ACCOUNTING ONLY; AIDI `--"- <br /> TAC# <br /> PE CODES rrF INrO AMOUNT RETv11T7Eb - <br /> CNECK/ICAS11—1 RECFIVFO py DATE PE'TIMIT/SF7IVICE nEGUEOT NUMBER <br /> 1 •v� — ��s ��— <br /> INVOICE <br /> Pub.Health Serv.-Enviro.173(3/96) - — <br />