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APPI.ICIITIOW FOR WELLIPUMP PERMIT <br /> SAN .IOANIN COUNTY PUBLIC HEALTH SERVICts <br /> ENVIRONMENTAL, HEALTH DIVISION O <br /> P-0- E#OX M 3D4 F—A,;T WEBER AVENUE, STOCKTON, CA 962010 �i��ii <br /> (209} 469.5420 <br /> AfOP9•IIEFIIf�paBiff FEI{IRIT EXAIAES 1 YEAR FROM DATE ISSUED <br /> ata <br /> APPLICATION f8 HERE RY MADE TO THE SAN JOAOUIN COUNTY ron A PEFONT TO CONST�RUCTIANnfOR�INSTALL 714F WOW VESCAIREO,THIS APPLICATION IR MAVF IN COMPI-SRNC <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE RTANOAROIT OP SAN JOAOUPN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL.MFALTH Dm.gjON, F VIKFH S1P4 <br /> JOB ADDRE87yOR APNY CFTJ -C.� <br /> PARCEL SIZFIAFY.rf <br /> OWNER'S NAME_L7�'f11v Y �um r l�D TA+.=p _ <br /> AUDRFBs CSJ���c'., <br /> .�. ---- - T �� !3? ! PFIRNE0._8Z3_663 . <br /> CONTRAC.TOR__ L.� f,L - Ah[xiEBR [��+y��� <br /> � UC SI PHONF A_� tT 1_7 <br /> RUR CONTRACTOR ADWIFSR <br /> .._. --�. -__. _.. .-.... _. ---.•-- UC• .PHONE.F_ <br /> TYPE OF WELI in MP: ❑ NFW WELL ❑ REPL.ACF.MENi WELL �tEl MONTTORINO WELL OTHER <br /> ❑ INSTALLATION ❑ WEI L SYSTEM RF,PAIR LJ CRn."-CONNECT AFFAIR ❑ VAPOR EXTRACTION WELL 1✓_ <br /> ❑N—rEI fbPelr . .__� OFT7fPUUP SEQf1YPE OF PIMP) _ FTFIRST WATER LEVEL� <br /> _�Relbf,r _ JO <br /> OUT-OF-SERVFCF.WELL ❑ OF.OPIIYC,ICAL WELL 0 ❑ 60R BORING <br /> ❑DESTRUCTION! R I — <br /> INTENDED Ub>: - -. TYPE OF WELL �... _... "— <br /> CONS7RlfCTIOpl8PfGfFICAT)ON8 ' - - — ------- - - <br /> ❑ IN RIAS <br /> ❑OPEN ROTTOM VIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CARING <br /> Q'DOMEqTIC7MtIVATE ❑GRAVEL.PACKISIZE -- i' <br /> TYF'F OF CAl;INCilATFFUPVZ',— GIA.OF WELL CARING <br /> ❑ PURLICIMIINICIPAL ❑OnIVEN - ------- O <br /> bF.F'TSI OF GFIOLFY SEAL SPECIFICATION <br /> ❑ IRRIOATIONIAG ❑OTHER ^------ �` ` <br /> GROLfT SEAL IN[dTAI.,I_EO BY GROUT BRAND NAME <br /> ❑ MONITOR1Nti �-y �-y ----- v...._yy.--_��_ E <br /> OnDIIT SFAI.PUMPFO; ❑Y. 1.,_f Nn CONCRETE PFDF.STAL BY DRRl.ER:❑Yam I_L Nrr T <br /> APPRa X.OEI'TH r <br /> LOr,KING CHESTER ROXIIiTOVF PIPE ' <br /> PROPOSED CONBTRLICTIONMWLUNO METHOD; MUD ROtARY <br /> AIR ROTAI;Y _ AUGER CARf.Ert <br /> OTHER <br /> 1 HEREBY CERTfFY THAT 1 HAVE PAFPARFD THIS APPLFC ON AND THAT THE WOW WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,FATE LAWS,ANO F{UI E$AK;i + <br /> 71419 PERMIT <br /> 1 OF THE RAN.I AOUINLL NOT COUNTY, HOME OWNER OR LICENREb AGFNT'S MONATIJAE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE.OF TffE WnRK FnR WH:CfI <br /> THfs PEnM1T IB taSUF.O,I SHALL NOT EMPLOY PERRONS SUBJECT TO WORKMAN'S CORAPIPRIIATION F AWS OF CALIFORNIA,' CONTRACI'Oq'S HIRING OR BIIS CONTRACTING SLGNATUf:E CFRrrrIES <br /> THE FO 'F CERTIFY THAT IN AHE PERFORMANCE OF THE VVOfV<FOR WHFC}i THIS PFRMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CO ATI I_AWg r}F <br /> CALIFORNIA.'.RNIA.'. CANT MUST CALL 2♦FM11RR IN AD NCE FOR ALL REOLRRFFI IN i1P IONS T f?Ofl IBS ,Ea, COMPLETE DRAWING AT LOWER AREA PR(IVIDEV, <br /> Signed X <br /> TItIA �J <br /> �i,(,e��p <br /> PLOT PLAN In'".to Bee1e{Rr'+1e 'to <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING T11F PROPERTY, <br /> 2. OUTLINE OF THE PROPERTY,OIVINO DIMENSIONS AND NORTH DfRECTIGN. 4. LOCATION OF HOUSE SEWAGE DISPOSAL RYBTEM OR MIOF'OSkh <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND['ROPORED EXPANSION OF REWAGE DISPOSAL SYSTEMS. <br /> STRUCTURES,INCLUOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIJtB, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HIJNDnFD FIFTti'r5', <br /> ON THE PROPERTY OR ADJOINING PROPERTY, , <br /> 7. <br /> F7 <br /> I <br /> fJ1ifY4 Cd�TyrlliA`� <br /> k� <br /> I <br /> r I <br /> .. .- -�'„-�r+�-• ;rte----�r—��� '"'�'- '."''. <br /> !e <br /> 777777�] <br /> I OFPADTML:NT UAF ONLY <br /> - i <br /> -- Dfln <br /> Groul Irieppclfen LIy <br /> --.-...._... — .�Pump 1n0t—tlen Ily / <br /> Vnlnu:tlnn Inenntlian BI. <br /> —..__.._._..�. Yate <br /> ACCOUNTING ONLY: AFOp -�. .—• FALA? ��_.--� <br /> PE CODES FEE INFO `AMOUNT RWITTE0 .ffECICfA,114 RECEIVED BY DATE <br /> PFAMITISgACE REQUEST NUNIMER INVOICE, <br /> (D <br /> $with$erv.-Envira.173(3/96) <br />