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O asfy�`3 <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �> P,O,BOX 388,304 EAST WEBER AVENUE,STOMON,CA 95201368 <br /> 2 u v (209)488-3420 <br /> NOR•111fUBDASLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> MomPI*u In Tr1Prmaul <br /> APPLICATICN IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERNIFT TO CONSTRUCT ANDAM INSTALL THE WORK DEDC111SEO.T1416 APPLICATION IB MADE W COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELORAENT TITLE,CHAPTER 9-111 6.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVAPON. ' <br /> JOB ADD/ES*lOR APR! CRY �7/Ir PARCEL SREIAPN9 <br /> OWNER'S NAME L/'Y�ILL It iA rC jLI V1!f'T.[Y` C' ADOIESi[ G/ff�`LJN-! _ c• PHONE' <br /> CONTRACTOR ,„♦��Q.{'� L]a�1/�(IA Q AbMESR�� /!X✓�S O t LIC✓k�iTJ�2 PHONE 1 r <br /> WS CONTRACTORLy ADDRESS LIC! PHONE E <br /> RU <br /> TYPE OF WELLMq/b7 NEW WELL E3 NEM AEPLACEWELL ❑MONROWNO WELL Al ❑OTHER <br /> 1❑`INBTALLA-rim [IEJ <br /> WELL SYSTEM REPAIR ❑CROBS•CONNECT REPAIR ❑VAPOR MOCTION WELL• J <br /> LJ N—❑KpNr H.P. DEPTH PUMP SET_PT. HRST WATER LEVEL O <br /> RYPE OF PUMPI <br /> ❑OUT-OF-SERVICE WELL ❑OEOPHYSICAL WELL F ❑ BOIL OORINO 9 <br /> ❑DESTRUCTION: <br /> TD I'll Wp1 CONSTRUCTION SPMFICA ONS A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION ` DU.Of CONDUCTOR CASINO p <br /> ,�RDOMESTICNWVATE RAVEL PACKBI2E TYPE OF CASING79TEE11PVC DIA.OF WELL CASINO D <br /> ❑"IJCiIAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEK l I SPECIFICATION A <br /> ❑IMOA7 WUAO ❑OTHER GROUT SEAL INSTALLED BY _ GROUT BRAND NAME E <br /> ❑MOwTOPoNG / GROUT SEAL PUMPED:aY- ❑Ns CONCRETE PEDESBRILLEII❑Yr TAL 39;4, 8 <br /> APPROX.DWT14 �L1Jf! �V I•� �� LOCKING CHESTER BOXBTOVE MPE 8 <br /> PROPOSED CONSTRUCTIONTRLUNO METMOO: MUO ROTARY C, AIA ROTARY AUGER CABLE OTHER <br /> 1 HEREHI <br /> BY CERTIFY THAT I HAVE PREPARED TR APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WTTM SAN JOAQUIN COUNTY ONOINANCEB,STATE LAWS.AND RULES AND <br /> 11EGUTAT10N6 OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGEPTT'e SIGNATURE CERTIFIES THE FOLLOWING;h CERTIFY cERrY THAT THE PERFORMANCE OF THE WORK FOR'A"CH <br /> THIS PERMPT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'*COMPENSATION LAWS OF CAIiFORNU.'CONTRACTOR•*HIRING OR SUS-CON771ACTR4 SIGNATURE CEKTEIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR:FOR NMICH TRIS PERMIT IB ISSUED;I SHALL EMPLOY PERSONS SUBJECT TO WORJOAAN'S COMPS SAT1ON LAWS OF <br /> CMJFORMA.'�T//r APPLICANT MU,T CALL <br /> 24 URS IN ADVANCE FOR ALL M4LW"IN`rUWTIONS AT 12000400-3422.COMPLETE ORAWING AT LOWER ATEA PROVIDED. <br /> Slprd%. V.CTC. TYT.��'T.(YY Tltl• UNZ Yt 0— <br /> PLOT PMN IDr—m S•ral Sul• <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE OISPOBAL SYSTEM OR PROMBED <br /> 2.OUTLINE OF THE <br /> NNG PROPERTY,GRDIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMe, <br /> 0.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WRMN MdUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS BUCH AS PATIOS,DWVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ��. <br /> .o. <br /> ; <br /> ...:.... . : <br /> r <br /> . ch FEB:. <br /> ...... <br /> ,........... <br /> ---- <br /> $. 1 <br /> . S0.hJU,iUUIh <br /> - CUgJC 14EAI"., 'SER' C S: '. <br /> : <br /> . _.. .. ... . . N>Jb'iANislEt ?!:HEiAL1'Isi'IIVF$IUNi:• `i— <br /> i <br /> DEPARTMENT USE ONLY ' 1 <br /> novn•.Ibn Aa•Pted Bx / .I�l L7(�G�J•� o.I• � .A<w-�_ <br /> G,•W In.Pactlan SY NC->'— / •�— �,O.ts�P—P In.pectlen By _D•I• <br /> Ouvmtbn B—d—By n c/ bna <br /> c•mn,««,r.: l C�t(_i." `�11_ �n� � Sc.^-el � �Z-'�1�� ' g <br /> 14, C, C � — z v&, GLLLLI'o tt,o <br /> ACCOUNTHO ONIY: HIDA FACT <br /> PF.CODES FEE INFO AMOUNT REMITTED CHK ASH RECEIVED BV DATE lltTISEMCE REOU" ER INVOICE <br /> �7If <br />