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r <br /> ,.� APP1 V.ATiON FOR WELLIPUMP PERMIT <br /> SAN Jf'' 'i COUNTY PUBLIC HEALTH SEI. ES <br /> UNMENTAL HEALTH,DIViSION <br /> P.O.BOX 38a,304 EAST WEBER AVENUE,STOCKTON,CA 95201 W <br /> 1299]M-3420 <br /> NDN-REFUNDA9LE PETIMIT EXPIRES 1 YEAR FRAM DATE"SU" <br /> 7 ILBmplele M Tr4lkatsi <br /> A PERMIT TO CONSTRUCT ANDTOR INSTALL THE WOW DISCRIBFO.71118 AmICATION 16 MADE IN COMPLIANCE WRH E <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOVIR COUNTY FOR <br /> 5 HEALTH SERVICER,ENVIRONMET7TAE HEALTH DIVISION. <br /> JOAOUIN COUNTY DEVELOPME�N7T TrtLEE,,C14AFTER S--,11115...33 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC 7f J�a-J�1 Z//9 CITY PARCEL SU!VAPN/ T� ie— <br /> JOB ADDRESSJOR AT'N1.-. __ <br /> OWNER'@ NAMEAODRESe •0, � L /SLW+ .. PHONE l HL�'1�'� <br /> Q fU ADDRESS uu�I9rYlS PRONE1 <br /> CONIRACTOR <br /> _ ADDRFBB LICF�7�bQ PHONE/ 8 71 <br /> SUS CONTRACTOR ff----rr rr.�( - - <br /> TYPETypE OFA L-I NEW WILL ❑REHACEMENT WELL T^7�1 MONtTORINO WELL f ❑OTHE R— <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR L CROSS-CONNECT AFFAIR ❑VAPOR EXTRACTION WELLr <br /> I�TL.,.r❑Ilebdr N9. <br /> DEPTH PUMP SFT FT. FIRST WATER LEVEL <br /> T-�R-YPE OF PUMPI 13O�.OF-SERNCE WELL ❑OEOPHYELCAL WELL I ❑ SOIL BORING <br /> L DFST RUCTION: <br /> r INTENDED USE TYPE OF WELL CONaTI,UC1104 BPECIFICA710Nf •7•�//i <br /> ❑iNOVSTRIAI Cl OPEN BOYTOM DIA.OF w[LL ExCAVATION E DIA.OF CONDUCTOR CASINO_ <br /> ,LDIA.OF WELL CASINO ~ <br /> ©DOME8TIC/MVATE IN GRAVELPACK!@ITE*� TYPE OP CASINGIRTEEL/PVC HPECIFICATION <br /> '�PV@LICAAVNICIPAL ❑DRtVEN DEPTH OF GROUT SEAL C <br /> f SEAL MSTALLE9 BY(?M4,--OCl0r _ GJ40UT BRAND NAME <br /> GRD17 <br /> ❑tMGATIONfAG ❑OTHER � <br /> GROUT SEAL PUMPED:Sly- Due CONCMTEPEDESTALBY MLLER: ❑ <br /> �❑Yw Ha <br /> A"ox.DEPTH 4.FT,f _ LOCKING CHESTER BOXMTOVE PlrE P5 <br /> PROPGBE4 CGNBYRUCTION1pOLLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABII <br /> OTHER <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THe APPLICATION AND T1fAT THE WOIR"LL 'I <br /> DONE IN ACCORDANCE WRTH BAN JOAQUIN COUNTY ORDINANCES,STATE IAWB.AND RULED, <br /> REGVI AT10HS OF THE BAN JOAQUIN COUNTY.NOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWUW''I C[MIPY THAT IN THE PERFORMANCE OF THEN UI I'OR V4F <br /> ALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPPISAT10N LAW@ OF CALIFORNIA,'CONTRACTOR'@ HIRING OR OUR-CONTRACTING f:I0NATURE CEFM <br /> S PEAMrt 1@ iBSl1ED.1 BN a SUBJECT TO WORKMAN'S CGMPEJEBATION LAWI <br /> TM EMPLOY PERSON <br /> ' ISSUED-1 SHALL EMR <br /> THE FOLLOYYING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WGRL FOR WHSCH THIO PERMrt IB @SUE r <br />. CAUFOFINIA.' T APTU NT M09 C=I"ADVANCE FOR ALL•REOUKI��S►EOTUONE AT t20B1'ESSJN2S.COMPLETE DRAW11K1 AT LOWER AREA p110V117E0. <br /> @ s^..I x <br /> Z TLe7. D.I.�f77�9! -- <br /> PLOT RAN 01—le 6-0-1 8c,.1/ 'to . <br /> S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 1. NAMES OF STREETS OR ROA 8 NEARSST TO OR BOUNDING THE PROPERTY. .FXPANSION OF SEWAGE DISPOSAL SYST EMB, <br /> 2.OUTLINE OF THE PFOVERry.GIVING DIMEN@lONS AND NORTH DIRECTION, E,LOCATION OF W[LLB WR NIR RADIUS OF ONE HUNDRED FIFTY FT. <br /> ].DIMENBN)NED OVTUNEB ANO LOCATION OF ALL EXISTING AND T'ROMSEO ,OFI THE pFWP[REY OR ADJGINtNO FROPEFTFY: <br /> BTRUCIVR.ES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. <br /> 799 <br /> WMi J HUNTER 6 ASSOCIATES <br /> 2229 LOMA VISTA OR(9161972.7941 Zz19 O� I1-35/121D <br /> SACRAMENTO,CA 95825 ss 323 <br /> ECJ 8y�` <br /> _ PAY 10 THE. .... - <br /> I <br /> d Q L L A R S Qv � <br /> Bank of America CtlstGINEr,Sinrt <br /> F Arden-Morse 73-0#0523 1 9 9 <br /> I�_ ? 3101 Arden Way - <br /> - Sacra a to,C 958 {9161 373-6920 _ <br /> MEnaU .. <br /> h <br /> I`I <br />€ L, <br />' f DEPARTMENT USE ONLY <br /> Appllcirle7A �Id <br /> T <br /> OraN M»beCNon BY Dal. P—P 1n.Pe°llen BY Del/ <br /> f <br /> f Arrlr�eNan Ir..Pmrlen BY - Deu <br /> E Cemme W - - <br /> I - <br /> ff ACCGUNTINO ONLY: AIDS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKOXABH RECEIVED BY DATE -POM WSIRVICE REOUEAT NL1MS9l -INVOICE <br />