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LIGATION FOR WELUPUMP PERMIT <br /> SAN UIN COUNTY PUBLIC HEALTH SERVOS <br /> NVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <br /> PAYMENT (209)46e-sa20 <br /> nECEIVED ICO+7. <br /> NON•OEFU111�S1E EEN/C�,.W..r,��svplus . TUN flQX_ ISSUED <br /> IC <br /> APPLATION NI IRK .N(O T/WSW <br /> �� R 1}IQAOUMI COIMry FON A PERIL f TO CONSTRUCT ANDIDII NuALL THE WOR(DESCHIND.TINS APPLICATION S MADE IN COWUTANCE WRN SAN <br /> JOAOUN COUNTY jj�� ER��•}1-1 15.3 AND THE STANDARDS OF SAN joAOUW couwv PUBLIC"MTN if.ENVIRONMENTAL HEALTH DIVISION, <br /> JW ADOILMJpRbZm=z weS/ CITYQ.�� <br /> H PARCEL SIZEMPN/ 'i <br /> V - ADORES. s / R KC /! '� ,N7NE?g6�j'G'IY 0970 <br /> V ` r0�► , vV/2•r J'y1-�i ADDRESS /• PHORE'r —24ILZ- <br /> SUS CONTRACT AOOIREN_ S•c(� QUA-' <br /> 110/ PIIOIE I <br /> ❑NEW WELL ❑RBLACEMENf WELL ❑MONrforom WELLI ❑ 0TOMM <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> RYPE OF PLWM ❑N.❑�.k H'P' DEPTH PUMP SET FT. FIRST WATER LEVEL J <br /> ❑ OUT•OF-SERVICE WELL ❑OEOPIIYSICAL WELL 1 ❑ SOIL Somm <br /> )ODESTNICTION .2 r O z <br /> Eap LNDUSTNAL ❑OPEN aOTToM VIA-OF WELL EXCAVATION_ �/1 K DIA,OF CONDUCTOR CASIq 7I /7 A <br /> VISI LIOMEStICRNVATE po GRAVEL PACKIMZE� O <br /> TYPE OF CASNNO/STEEUPVC_�IJ*G DIA.OF WELL CASINO <br /> ❑RNfUCARINK:IPAL ❑DRIVEN DEPTH OF GROUT SEAL G O <br /> ❑ISSGATIOWAG ❑OTS L SPECIFICATION s <br /> ORDUT SEAL INSTALLED BY IL GROUT BRAND NAME <br /> ❑MOINTORIq OROUT SEALPUMPEo:❑Y. ❑RIO E <br /> r,,�/�A{CONCRETE PEDESTAL BY ORRIER:❑YM Nr, s <br /> APPROX.DEPTH_. "l. J LOCKING CHESTER SOXIISTOVE PIPE <br /> M10Po{q S <br /> METNDDs MUD ROTARY AM ROTARY AUGER_A _ LE OTHER <br /> 1 NERHY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL LE DONE W ACCORDANCE WITH SAN JOAOUNN COINITY 01101NANCH,STATE IAYVs,AND RULIS ANO <br /> ILGULATIOIN OF THE SAN JOA COUNTY. HOME OWNER OA LICENSED AOENT•S SIGNATURE CERTIFA T1Q FOLLOWNNO:'1 CERTIFY THAT IN THE P WOMAANCE Of TINS WOR(FOR WHICH <br /> THIS PERMIT IS NSUM,I SHAH NOT EMPLOY PERSONS SUBJECT TO WONIMAWS COMPENSATION LAWS OP CALWOMIA,' CONTRACTOIT'S ISRNG Olt SUN-CONTRACTNq SIOHATINE CERTWaS <br /> THE s 'I CERV IFY THAT IN THE PEIEOMAANCI OF THE WDRL POR WINCH THIS PERFNf IS SSUEO,1 SHALL EMPLOY PEMONS SUBJECT TO WORKMAN'S COMPENSATION U1VYS OF <br /> C ANT MLNT CALL 24 i10Ulis W ADVANCE POR ALL REGUNRW I/NECTIONS AT I2N)E�NiE13 COMPLETE ORAVNNO AT LOWER AREA PROVIDED. <br /> TIIb Def• <br /> PLOT FLAN oew b SWN hW�_• /'Yt� <br /> 1. SOP STILETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PRIOPORNto <br /> 1. OURE'a OF THE PROPERTY-WVVM DNNENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMlNMO ED OUTLINES AND LOCATION OF ALL EXMTINO AND PROPOSEO S. LOCATION OF WELLS WITISN RADIUS S T ONE►RRNVIRED FART/FT. <br /> STIIIICTUNLt,INCUR+IIG COVENtO AREAS SlIC11 M PATIOS.ONVEWAYS,AND WALKS. ON THE P1101 TY OR ADJOIQN PROPERTY. <br /> ......?.....{......{ ...¢.....i ...4...... ............. <br /> { <br /> { i { t....... i......t i <br /> { t <br /> .............T......s.....p............{............p... i { _ ! { <br /> i ! �.. {. p......i . t ° i..... s <br /> ,.�, ...... {.....(. {.. .....E p.... <br /> . <br /> I <br /> t <br /> . .. .....y...........:... .. <br /> : <br /> y.....:....:.....{.....y......:... .p.....:.. ........:....p...... ..,i........... j... .. .�.. ...i.... ....t.. ..t <br /> .....{......p.....i......4....... <br /> .....y......{.....y......:.......}.. ... <br /> • ....... ...t......:......j..,. .. <br /> :.. <br /> ...�;........ ..n.....:.. <br /> t <br /> .................}......................y.... <br /> ........v......:.....y.. ...�...... <br /> ... <br /> ....{..... <br /> ..... <br /> . ....... ......... <br /> { t <br /> :....;....i.....;......E.....y....:.. ..{.. ......... <br /> i...... <br /> i <br /> • d. <br /> ... .:....:..........{.....7.. .. ... }......:.....y <br /> C <br /> n.... ......{ .....' ..... .. .. ..... <br /> { <br /> , <br /> �... .. ............. ,..........y................ <br /> { <br /> { <br /> { <br /> 2 <br /> : <br /> y.. ......... ............ <br /> ... .. .. .. ........}.........y. ........}............ .. <br /> .......:.. <br /> :. .. : ...<............ . ...>. >....... <br /> . .Y.. <br /> Io -� <br /> .•�.. .p. .••7••.. .. y. t <br /> ..y.....{......;. .. I ! t <br /> : { <br /> : <br /> { <br /> i <br /> DWARTMENT USE ONLY <br /> Apel-dM Astn/b/LIF �f� �c— W1SpM p1 <br /> arw Mw�EIMn Pump 6"-d—Sr vDM: yFti r <br /> O.EIrIrIIEn InEps <br /> CEwrnrlM: _'w <br /> AOCOUNTWO MY: ANO/ / �QN daa <br /> PSDOGES ININFO AMOUNT REINTTIM ASN NwIll O EY DATE PIViNTISVIVICS 11SQULNST MURINE MIVOIOE ' is'1 <br /> •S��+A6- -t: <br /> �L <br /> Pub.Hsakh Som-Envlro.173(1/87) <br /> r <br />