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APPLICATION FOR WELLIPUMP PERMIT <br /> law., SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N.SAN JOAOUIN ST, STOCKTON, CA 96201 368 <br /> r t (209) 4883420 <br /> NOBNEFUNDABIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICrme,le.Y TO hestal <br /> ApplEcNtfon is here by made to the San JosOuin Cont, for a permit to cone Lrt,Ct ar,d/or install the work describe t. This application is <br /> made in compliance with Sen Joaw,u:n County Development Title, Chapter o-•1:5.3 and the Stereards of San Jomwufn Canty Plbltc Wealth <br /> Services, Envirorm-.n:al Health Division. <br /> '� Job Address/pr ACMI /0�9g J. AIA i?y,p/_1/al^ CITY 60 �/'1/•'�� Da'Cel SI1e.rAPM/ 'f/'--(���/2. <br /> Owne-•a Name/W11Qr�CAN7� 'Ft���563ress�/ ����7� 2� MG['1Eli�nore • 'f TJ-�iE/�?S <br /> Contractor u. �'FrP iFoci -z, J Cfi & 4342/F' Ph, #-G <br /> `Sub Cont rat tvr 'm-ess Lice Phen� <br /> TYPE Or Vrkl.(PUMPi ❑ NEW ALL I1 REPLACEMENT WELL ❑ "TIMING WELL a ❑ OTHER <br /> \, 71E DESTRUCTIW [1 OUT-OF-SERVICE WELL 11 GEOPHYSICAL WELL a _ 11 SOIL SOR ING _ <br /> INSTALLATION U WELL SYSTEM REPAIR [1 CROSS LWNECT REPAIR I1 VAPOR EXTRACTION WELL R_ <br /> _ [( New [I4epeir M.P. DEPTH PUMP BEi FT. FIRST \AVER LEVEL_ <br /> \(TYrn- OF PUMP) <br /> � _ U.•fD 34.�-1�v� t�-t � T L ir'[I-(1F ��•k ( F! rAh <br /> SIF' DFM ED US[ TYPE OF Y'IU QRSTRUCTION SP CIFICATIONS G <br /> 11 INDUSTRIAL 11 MEN BOTTOM DIA. LF WELL EXCAVATION___ OTA. OF [OMDUCION CASING_ <br /> IS DMMESTIC/PRIVATE (I CRAVEL PACK/SIZE TYPE Of CASINC/STEEL/PVC__ DIA. OF ALI USING _ <br /> I) PUBLIC/MJN ICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL__ SPECIFICATION <br /> (I IRRi WTIW/AL [1 OTMER GROUT SEAL INSTALLED BY GROUT BRAID NAME <br /> Crl U MONITORING / �. WW1 SEAL PUMPED: [I Yes U No CONCRFIE PEDESTAL BY DRILLER: 11 Yes L1 NO <br /> !�APPROX.DEPTH W^F—/ LOGGING CHESTER 80X/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_AUGER__ CABLE_ OTHER_ <br /> —• W 4 f 7 P 6f-,&I 6-1-0 L)E <br /> 1 Aerable certify that 1 have prepared this IPpl itatlon are that the work II De dors m accordance with San JoaWm Canty Ordihancas, <br /> State Laws, and Rules and Regulatiau Of the San Josaj in County. None owner or 11<eesed egmt's Signature certifies the following: •1 <br /> certify that in the perforaunce of the work for Which this permit is issued, I shall rot eaploy perseres stbject to=KPAN'S COIRENSAT[OI <br /> Laws of California." Contractor's hirinp or sub-<ontractiN sigrMture certifies the f0ilow.N: w I certify that in the perf0r ,, <br /> of the work for Which thi permit Is Issued, I sh.IL o toy Persons Rlb)ect to ARKMAN'S COMPENSATION Laws of California.• THE APPLICANT <br /> MUBY CALL 21 I. II 01 ACE FOR Ll A EKED INSPECT IONO AT 8011 Fall Coapl ate draw i rq at r ares provided. <br /> L— <br /> Signed X F/s /G Title l Ag?, L Dat <br /> 4101 PLAN (Draw t0 Scale) Scale " to <br /> 1. Name+ of streets or road+ nearest tC or bcuclin, the oroperty. A. Location Of home sewge disposal systs of <br /> 2. Out Line of the property, giving dimensions srd North direction. proposed espans Eon of snug.disposal +Yater. <br /> 3. Oisensioned outlines srd location of atL eMi etinp end proposed 5. Location of Ws11+ within radius of 150 ft. m <br /> structures, inCLUCIN covered areas such aspeTip�OrivaWaWer the property Or adioininq 'Ciwrt Y• <br /> Hal walk. <br /> AI I <br /> JA I <br /> lull Ze <br /> G <br /> DEPARTMENT USE ONLY �i/1•< ) <br /> Arp!lcatlm Accepted By <br /> ' / Date <br /> Grout Inspection BY Date Pulp Inspection BY 1 1Date_`_ <br /> / 1 (. -L U Oet e!C%ll�ti t/ eomments-!(�I •� Il�k+tV`p E.V a«•� . .twol <br /> Deatruc[ien Inspection By — rT— <br /> O(Ly\ ( (SIE 1 <br /> ACCOUNTENO ONLY: A1DN <br /> PE CODU FEE LAID A U.1T NFMITTEO IFCA X RECEIY[D B7 O11E PERRIi;IFAYK[R[DU[ST MUNNEt INYOK/ <br />