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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 986,904 EAST wF-ar:R AVENUE.Sl'OcmK CA 95P i w <br /> (2081469-3420 <br /> NOWNEfURpABIE PMW EXPIIIFS I YEAR FROM DATE ItIll10 <br /> ICormllTl Is TriPBoW <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRISED.THIS APPLICATION IB MADE N CfAAPLlANCE WITH SAN <br /> JOAWIN COLNrY DEVELOPMENT TITLE,CHAPTER 9.1 115.3 AND THE ETAQND�%03 OF SIN JOAQUIN COUNTY PUBLIC HEALTH a61VICEa.ENVIRONMENTAL HEALTH DRLTpON. <br /> JOB ADM@m APNA TZj Z& _ g (266 Ie.! CITY l7C+firC_T <br /> �PAICEL LaR1EAPXi <br /> ov~v NAMErA 9 LY'rid .- IL4 � 13 <br /> -T 1- PVA)E,_234 <br /> ^ :-:0 <br /> CONTRACTORV LA ,Za� _o ADDRESS PHONE#5? <br /> SUB CONTRACT" <br /> "Co PHONE <br /> TYPE Or wtu ymp ❑REw v L ❑ REKACEMMT WELL ❑MGMTONNG WELL I ❑OTNER <br /> Q� ❑INSTALLATION 13 WELL SYSf[M REPAIR ElCROeS-CONNECT IEPAN ❑VAPORE%TPNCTIONH <br /> WL S J <br /> 13N-13ra�n DEPTH nmw SETj�aPT. FIRST WATPA tlVlL O <br /> ' r��1r.S Yl_Gy ❑OUT-0F.SERvICE KF11 ❑SEOPHYe1GL WELL, ❑ SOIL ZORNO a <br /> ❑OESTIB c-mN,. e- <br /> Dm CONSTPXVTIPN amwwpTl A <br /> El 13 OPEN BOTTOM DIA.Of WELL EXCAVATION MA.OF CONOUCTOIt CASNG <br /> Z=TW)'RIVATE ❑GRAVEL PACKARE TYPE OF CAgWMWEEUPVC DU.OF WELL.CASINO O <br /> ❑PUSIJC/RRIP' AL ❑DRIVEN DEPTH OF GROUT SEAL _ SPECEiCATION R <br /> ❑SVBDATXWAG 13OTHOI GROUT SEAL INSTALLED BY _ OROITT BRANDNAME <br /> 13MONITORrMT GROUT WAL PUMPED:13 Y- ❑M. CONCRETF PEDESTAL BY DRLLER❑Y- IJ N. <br /> AFPIOX.DEPTH LACKING CHESTER SOKfatOvE RPE <br /> P/IDPOSED COMSTYPIL ONMIRILLING METHOD:AM ROTARY_ NR ROTAIIY AUGER__WALE OTPEjj_ <br /> 1 HE`CSY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDM/Im VMTN SAN JOAOUN COUNTY ORDINANCES.STATE LAWS, <br /> ANO RILES <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICLNSED AGENT'*SIGNATURE CERTIFES THE FOLLOWNG:I CERTIFY THAT IN THE PEKOI MAMCE OF THE <br /> WOR(IDR <br /> THIS P09AT IS ISSUED,1 MALL MOT FIAPLOV PERSONS SUBJECT TO WORNMAN'B COMPENN1TION LAWS OF CAIJFORMA.'CON/Rl1CT0P1'S HNSNG OR WSCONTRACTINS SIGNATURE C9TTlRe t <br /> THE FOLLOWING: •I CERTIFY THAT N THE PUMAMANCE OF THE WOW FOR WHICH THIS PERMIT/1 ISSUED,1 SHALL EMIROY PERSONS SUBJECT TO TYORISMAR'S COMT6ISATNNL LAWS OP <br /> CJWPORMA.' T AMT MUST OALL/�].�LR{S ADV AMC!PORI ALL RSOLS AT b1' OMRME pNLMNS AT lDVY01 MEA p/ID.,VItwo. a/ <br /> SIirO.r X /' / �/.�,�/�� as ✓ -311 <br /> PLOT PLAN 0-M Saul e..I. m/ <br /> 1. NAMES OF STREETS OA ROADS NEAREST TO OR SOUNDING THE PRDFMTV. 4. LOCATION OF HOUSE SEWAGE DLSPDSAL SYSTEM OR PROPOSED <br /> Y.OUTLINE M THE PROPERTY,GIVING COMIISIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 9.DIMENSIONED OUTLINES AND LOCATION OF ALL EXRrm MIO PROPOSED S.LOCATION OF WILLS VHTHN RADIUS OF ONE MRiMED FIFTY FT. <br /> STRUCTURES,INcuma a COV97ED AREAS SUCH AS PATIOS.DRIVEWAYe,ALA WAIC.B, ON THE PROM"OR ADJOINING PROPERTY. <br /> .v.. .. ,: <br /> ..�.. .. .. ...` . .:. .y.. _ <br /> i <br /> ...i....:.... .. .:....... . . <br /> ....,.....L i..,..i....:......:......i... <br /> .....f...... ...... ... .`. ..5. _�... <br /> ...i... ....�....L....:_. <br /> ......e......:. ..:... ... <br /> I <br /> ......J. ...r.... iy.. _ <br /> ....?. ...7...... <br /> i...... ..?..... ......i... <br /> <... Ot is?. <br /> ..i......`......I. .>....... .........i... <br /> . . . .>....'.... fix <br /> # . . <br /> ............. <br /> ...... <br /> 2 <br /> ....:...... . ._ ...:......... ...... ...... <br /> .... ......... 4`4 ef,�.....:.. <br /> : ......;...... . .. .... ;......,.t LT SE ,i . <br /> ... :...........t..... ... yLriFiOirlw�{yI'�l1kyE/kofwH'11y/Iar„L.... <br /> ;.... . . <br /> ....... ;.. ;... <br /> ; <br /> OQMThIBIT USE ONLY <br /> ApPllar.n A..ybr By_ <br /> IV <br /> O,.M Mr.Peellon ey_ Urt. Pimp MupwH.n By -44 <br /> ' AIR DK. F <br /> D�I,wIlsn(nN:..1)An RN DAw - <br /> ea.n.n..e.: <br /> ACCOV*MNG ONLY: ADI' FACA <br /> PF Coate FBI ILO AAAOUrT REMITTED CMa AIN "WEVSO BY DAT! rammoTpurace R[OUEST NI1hOSt eiYDIO! <br /> 05D s0 Glr D3U(oS,7) <br /> d $3 <br />