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�.� .. I <br /> } LIGATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV=q, r . <br /> ENVIRONMENTAL HEALTH DIVISION - 4 "/ ( <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95?(? <br /> (209) 468-3420 <br /> j NOM-REFUNDABLE PERMIT EXPIRES J YEAR FROM DATE ISSUED ? , <br /> c IComplate In Trlptleala) 4 <br /> APPLICATION IB HERE BY MADE TQ THE BAN JOAQUIN COUNTY rOn A PFRFAII TO CONBTnUCT AND/On INSTALL THE WOES(DESCRIBED.THM APPLICATION 18 MADE IN COMPLIANCE WITII SAN•' <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND 7%!E ST NOARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH BERVICES,ENVIRONMENTAL FIfJILTIt OtY1SIO <br /> JOB ADDRESSMI AfNf flQ <br /> Clry PARCEL BIZE/APNf � t <br /> OWNER'S NAME ADOnE9e { t MOVE f <br /> CONTRACTOR ADOnESB EhBm( Ips , 44tha "AMI-mONE I 'J� '3IG/•. <br /> BUB CONTRACTOR ADDRESS / r LICE 4 PHONE f <br /> TYPE OP WEL MPI ❑ NEW WELL ❑ REPLACEMENT WEII ❑ MONIT ORINO WELL f OTI1E �» * ~• <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REP lr l�G y XT1( /Ji .WCL I J <br /> ❑Naw Itapalr N.P. DEPTH PUMP BET FT. // QRST �E11�P1E 0 <br /> : HYPE OF PUMP) _`..;A Y I � <br /> ❑ OUT.OF-8ERVICE WELL ❑ GEOPHYSICAL WELL f ❑ BOIL SOMNO f ' <br /> H E>jT1iUFTK1a:-....w-..,,+., T• -..-..may..�1.-...........-..a..�-_:.:r'L►-::�......",�.....•�.'t's�,kr jyq�� X,.11.:r�1 rr.'R".t:�-.-r�.•.�•!�i:< +,» i� „».j.i-:: �-.. <br /> Typs Or WELtCONSIRUCTION SPECIFICATIONS A <br /> Q 1NWSTIEAL ❑OPEN BOTTOM <br /> I DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO - p <br /> DGMESTIG►'RIVATE GRAVEL PACK/SIZE 011eTYPE OF CASINO/STEEUPVC DIA.OF WELL CASINO 0 <br /> �-7 PV8UC/MUNICfPAL DRIVEN DEPTH OF GROW BEAL SPECIFICATION <br /> (E'J7 ROSGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY OnOUT BRAND NAME E <br /> Q MONITORING ( OnOUT BEAL PUMPED: Ely. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑YM.'.F�Ne d <br /> APPROX,.OEI'TH (J -LOCKING CHESTER Bo)=IaroVE Ri'E <br /> PROPOSED CONSTRUCT/ON/OWLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> f <br /> I FtE7EBY CR+�:TlFY )IAT 1{IAYE PREPARED THIS APPLICATION AND THAT 111E Wornc WILT.BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE t AWS,AND•RUI.ES AND <br /> REGULATION F e SAN JOAOVIH COUNTY. HOMED R OR LICENSED AOENT'S BIONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEIIFQRMANCE OF THEW HSC FOR <br /> -Ill#PEREHNT, 12,1011 ALL 1 LOY PERSONS S �IJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CQNTKACTOR'e HIRING OR SUB-CDHTRAGIING MNATVRE CERTIFIES f;;i' <br /> Of f.I cg ITII , IN HE fEEVORMA E OF THE WOEK ron WHICH mis PERMIT 18 ISSUED.I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'It COM►B/MTIDI�LAWB OF, <br /> C a Ho ADV E.FOR ALL REGUHRE6�INa TIGNS V-1 <br /> 14 -s4 JS.'COMF4ETE DnAVANa AT;LOWEM Ann^rmv$ v <br /> 81Sry4 X Title r G r �-• .i:... <br /> g <br /> PLOT PLAN to,"Ia Sual.)Bo.t. Ia <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO on SOUNDING Tiff Pnoptnry. '' 4. LOCATION OF HOU BE SEWAGE OI POSAL IYST EM On rMPOSED <br /> t. OUTLINE OF Tiff PROPERTY,GIVING DIMEN8fON8 AND NORTH DIEIFCTION. EXPANSION OF BEWAOE D18POS 4YSTEMS, <br /> 3. DIMENSIONED OVTUNFA AND LOCATION OF ALL EXI8TIN0 AND PtOPO FO S. LOCATION OF WELLS WITHIN S OF ONE HVNOMp f IFTf f T. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKe. ON THE PROPERTY OR ADJOIN", PE!". <br /> i -r ..'... .I <br /> ,.. ,- ... ...�., ...i....i.....•. ... AI - <br /> i <br /> - <br /> c <br /> 1 <br /> r <br /> / fie f8 <br /> s 1 ' <br /> wJ4 <br /> y vy r <br /> ;. <br /> krT <br /> ide v) <br /> CL <br /> H T; <br /> rr <br /> f n ' <br /> ' � SA.N JG' <br /> PUBLIC.H �CTHSERVIC�S t <br /> FN.�IP.QNA <br /> �.•-�'^ DEPARTMENT USE ONLY <br /> 6 6- <br /> AO►Ib.tlen Aae.Pted SY d.l� <br /> 0'"kwP"Itsn By Dot* P—P hwpaatfen BY Date <br /> DeNnwtlen kwp"tI—BY Dote _ <br /> r <br /> Cemmenll: <br /> ACCOUNTING ONLYt AIDE MCI <br /> 'IF coo" ' FEE INFO OVNT Ft MITTEb C/HECKFICASH RECEIVED■Y DATE PEFMRISERVICE REQUEST NUMBEST INVOICE <br /> Pub.Health Serv.-EnVirO.173(1/97) <br /> uClw, <br />