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APPLICATION FOR VVELLIPUMP PERMIT 0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVEALTH <br /> IP 0 BOX 388, 446 NRSAN JOAQUONMENTAL IIDIVISION N ST., STOCKT N, CA 96201.388 ReCEIVED <br /> (209) 488-3420 F E g 2 2 f <br /> PN/6 3-O(,0--6 NON-REFUNDABLE PERMIT EXPIRES 1 YEgR FROM DATE ISSUED C' <br /> APPLICATION UNTY <br /> IS HERE BV MADE TO THE SAN JOA0U'C0UNry FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. 1 An SAN JO.E A 17 -9ERV C <br /> JOAQUIN COUNTY DEVELOPMENT TITLE CHAFFER 9-1115.3 AND THE ERMITTOC OF TAN JOAQUIN/OR INSTALL <br /> PUBUC HEALTH SERVICES,ENVI�ygppO�/(8���EMAL H�EeAL,1 [N4DRVICES <br /> JOB ADDRESSIOR AM, //// GVRONMEN^"t°'N�MEIR/�IBMgIgNQCWAR <br /> -' IE COHQN - QT& If/'MG AN <br /> OWNER'S NAMBSS• /� 0 ASI- Cm Sl a�K t V/L/ <br /> EKTOAJ (fRJ, H JC Iec 'p r <br /> / , yT y �PAgCELb <br /> �IZE�APQNSY�Y- <br /> �.99 <br /> ADDRESS /.coxrgA'TOR � KD. Q65T-'9J <br /> SUBCONPHONE <br /> ovN R NC[669b� % SONE12/ <br /> !/ADDRESS <br /> Y <br /> TYPE OFA—MP ❑ NEW WELL U PHONEI <br /> ❑ REPLACEMENT WELL ❑ MONITORING WELL I <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ OTHER <br /> ❑Nay❑ ❑ CROSS-CONNECTREP' R ❑ VAPOR EpTMCT��� <br /> RYPE OF PUMPI gepab H.P. <br /> DEPTH PUMP SET�_FT <br /> ❑ <br /> FIRST WATER LEVEL <br /> ❑DESTRUCTION: OUT-OF-SERVICE WELL -- D <br /> ❑GEOPHYSICAL WELL i ;II (7 <br /> "�OOJ M7p(��N <br /> fa.2 e <br /> INTENDEDUSE TYPE OF\YELL PH K'S("I F'µJIKOLvpIKNr*41 <br /> ❑ INDUSTRIAL CON6TRUCTIO—CAIi��N6 <br /> ❑GRENBOTTOM DIA.OF WELL EXCAVATION [/ <br /> ❑ DOMESTIC/PINVATE ❑GMVEL PACK/SIZE � '1 <br /> DIA.OF CONDUCTOR CASING-- N <br /> D <br /> 1-] POBl1C/MUNICIPAL TYPE OF CA81NGhTEEI/PVC <br /> ❑DRIVEN DEPTH OF GROUT SEAL --- Olq'IF WELL CASING <br /> ElIRRIGATION/AG ❑OTHER �— D <br /> SEAL INSTALLED BY SPECIFICATION <br /> ❑ MONfTOgINp GROUT ffaa <br /> GROUT SEAL PUMPED: ❑Ya ❑ GROUTSRANDNAMEVEE/C CVTr/AUh i <br /> APPROX.DEPTH E <br /> CONCRETE <br /> _PFOE BV DWLLFR:❑Va ❑Ne <br /> PROPOSED CONSTRUCTION/DRIWNO METHOD: MUD ROTANY LOCKING CHESTER BO%/STOVE PINE �-iR"T Nromj y.' S <br /> AIR ROTARY ov <br /> AUGER LDHJ Ott wrt [� <br /> I HEREBY CERi1FY THAT I HAVE PIIEPARF.D THIS CABLE OTHER <br /> C E:4tT S / <br /> REGULATIONS OF THE SAN JOgpUIN COUNTY, HOME OWNER OR UCEN6ED AGEM'S SIGNATURE CERTIFIEe THE POLIAVRNO:•I CERTIFY THAT IN THE ORDINANCES. <br /> .ST OF THE WORK FOR WHICH <br /> THIS PERMIT IS I6bUE0,ISHALL NOT EMPLOY PERSONS BUBJECµT TO WOgKMAN'e OMPENBAIONELAW60FCgUµFCORN „p011TJgACTOIR'SATIN Oq 81UB{ONTggCTE SIGNATURESNRULE SAND <br /> CC4e� ,((/ <br /> THE FOLLOWING: •I CERTIFY THAT IN THF PEILFOgMANCE OF THE WORK POR WHICH THIS PERMIT 16188UED,1 BNALL EMPLOY PERSONS SUBJECT TO U WORKMAN'S N'6 LNG NAT LAWS OF <br /> CAOPOgNIA• NE PP IT MUST CA <br /> IN ADVANCE FOR ALL REGUIRED IN 110N6 AT I3o6I ABBJa�. COMRETE <br /> HAWING SUB AT LOWER RKEA N'S COED. <br /> glP etl X dy/ <br /> S,Z <br /> PLOT PUN Oraur to SCNaI 8uls Data <br /> 1. NAME9 OF STREETS Oq gOgpS NEAREST TO Oq BOUNDING THE PgOPERf V, 10 <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS OND NORTH DIRECTION. <br /> 3. DIMENSIONED OVTUNES AND LOCATION OF ALL E%ISTING <. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH XI PATIOS,D PRO D EXPANSION OF SEWAGE DISPOSAL SVeTEMB. PROPOSED <br /> RIVEWAYAND WALKS. 6. LOS, CATKIN OF WEDS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOINING PRKIK . <br /> _o- <br /> S( HE)DL <br /> / TF_ �/ I <br /> sr ;�� P7�C EQ F( t O F 8'uo� S <br /> 1 <br /> ye' IT)e N+W rfp ^ <br /> r`1 1 <br /> 3cIC[Jul�fl/I Fx[L�iv��•rr_PC <br /> ClC/t r/t i <br /> ' DEPARTMENT USE ONLY <br /> APPIIatlon Acc«le6 By ? <br /> De.— GAra <br /> Gmm Iro°ation By mt. Pump Ira <br /> P«non ey <br /> Detraction Ino«non 6r Dete <br /> Dae <br /> ACCOUNTING ONLY: AIDE <br /> FACk <br /> PE CODES FEE INFO AMOUNT REMITTED CH MASH RECEIVED By DATE <br /> P6NIIT/SERVICE REQUEST NUMB61 INVOICE <br /> y/ L3 0 <br />