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APPLICATION FOR VFELVPUMP PERMIT <br /> `SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICt/ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388,304 EAST WEBER AVENUE, STOCKMN, CA 95201388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICOmPIBte In TIIPRB&tBl <br /> APPLICATIONALL THE <br /> "AMU N COUNTY DEVELOPMENT TRIS,CHAPTER,S HEM BY MAM TO THE SAN 11111161.3 N COUNTY FOR <br /> THE STRANDAPDB OF BAN JOAQUIN IT TO CONSTRUCT ANCHORCOUTyNN�TYY PUBLIC HEALTH H GFIR ICES.IIS APPLICATION IS ENIRONMFNTAL HEALTHIDMBION.IANCg—J;EII SAN <br /> /1L D 46 I NNb BI Vd �CWY JIV4SI � PARCEL 812EIAKIR-a '�07�^' <br /> JOB AODRE88lOR ARU DDL( YA A DORE11:- n (� <br /> OWNER'S NAME rY...l L(y2((pp�,1 D44014h —AMM.. 21st Couawv LILIy ) ! ONE I,.ZD - 1028 <br /> CONTRACTOR Envllros.�11G AMMASTPo,BOX&159 Sumo rHONEE707�/3S''48Sb <br /> 8UBCONIRACTOR �IYpP.1�Q�,nF (q ADDREBegtol)� Rd o&&9 ucE4U14r RgNErs�` <br /> TYPE OF WEII/R1MP: �I NEW WELL ❑ REPLACEMENT WELL RQ MONDORING WELL/tAW ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS&CONNECT REPAIR ❑ VAPOR EXTRACTION WELL S <br /> ❑New❑Reeelr N.P. DEPTH PUMP ML-FT. FIRST WATER LEVEL O <br /> DYP OF PUMPI <br /> ❑ OVT-0FRERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOR BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& A <br /> ❑ INDUSTRIAL 11 OPEN BOTTOM '1 DIA.OF WELL EXCAVATION �7 DIA.OF CONDUCTOR CASINO /Q D <br /> ❑ DOMESTICBTIVATE to GRAVEL PACK/AI7F#_2L (�5ftVTVPEOFCASINGMTEEL/pVC PVL DIA.OF WELL CASINO If// D <br /> 11PUBUCMUNICIPAI ❑OmVEN QFIR DEPTH OF GROUT SEAL go, ��� SPECIFICATION R <br /> {❑�J1 IRRIGATIONIAB ❑OTHER GROUT SEAL INSTALLED BY h'1 U/NI/ GROUT BRAND NAME E <br /> W MONITOMNO GROUT SEAL PUMPED: BJ IpxTYs ❑Ne CONCRETE PEOEBTAL RV DRILLER:®Vee ❑Ne 5 <br /> APA,...OFPTH LOCKING CHESTER BOXISTOVE RPE S <br /> RIOPOSED CONBTRUCTIONGMeLUNO METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER <br /> I HERERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULER AND <br /> REOWXATIONS OF THE RAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTRY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IS ISSUED,18HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENBAIRON LAWS OF CALIFORNIA.- COMPACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 CEATIPY THAT IN TIIE PEAFORMANCE OF THE WNN FOR WHICN THIS KAMM IB ISSUED,1 SHALL EMPLOY MARGINS 6VBJECT TO WOREMAN'S CCMVEUATION LAWS OF <br /> CALIFORNIA.' THE ACAM USE ALL IN ADVANCE FOR ALL REOIXRW INN/&P�ryE/CMNN}S AATTPOIH IHHB 122. COMPLIME ORAWING/A^T LOWER AREA PgVIDED. <br /> n <br /> Rl, x 11 LZ TIGe__I`�Il"�/V//C(///� <br /> ALOT THE ROMFIe BOMeI Seels •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BAM NOR THE RECTION. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. DITFUNIFMENSIONED <br /> OF THE PMFKTLINF8 YN NINA DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMO. <br /> J.STRUCTURES. <br /> OUTLINES AND LOCATION OF ALL AS PATO AND PROPOSED S. LOCATION OF WELLB WITHIN RADIUS OF ONE HUNDRED FIFTY ET. <br /> BTRUCTryU11E8,INC[LNwV�D�IQN�O�COVERED AREAS SUCH AS PAige,DRIVEWAYS,AND WAIKB. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> /� DEPARTMENT USE ONLY <br /> Db_ bo <br /> OrorA Imoarlon BY ON. Rmp InePmllan By ' <br /> DHA <br /> Deehm,len Imnecllor.By <br /> cemmr.,,. <br /> z rcl wLc..1 G[JU S S agr[¢cn+o+ p6K <br /> R_ 2-A „o '� <br /> Pmfl(a F�L aN n2aS <br /> — v-- <br /> ACCOUNTING ONLY: AIDI <br /> FACT <br /> PE CODES FEE INTO AMOUNT REMITTED CHECKOMASN RECEIVED SY DATE IRSNBM CE REQUEST NUMBER INVOICE <br /> 3501 (,g <br /> o. <br /> Pub.Health Sew.-EnvirO.173(3/96) <br />