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•' �� APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICED <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 988,904 EAST WEBER AVENUE,STOCKTOM,CA 95201388 <br /> :1209) 400.3420 <br /> F—ag-AtfUNDARLE PERM11 JXPIM I YEAR FROM DA 13SUED ; <br /> IGmp19q AB T11pRauX <br /> APPMAT1DN IS IRRE BY MADE TO RIFE @AN JOAQUIN COUNTY Fan A PERMIT TO CONSTRICT ANDMR IMOTALL THE WOW DFSCGMFD.Yale APILICATR/N IB MADE M COMPLIANCE WIT"BAN <br /> JOAOUIN COUNTY DEVRONAENf TITLE,CHAPTER M116.3 /THE STANDARDS OF BAN"ADM COUNTY ELIC H LTH BERVICE9.ENWRONMEW AL HEALTH DMBTON. ' <br /> 'JOSADDREBRMFI APHf O V �- —Cr, PARCEL BIxFJ <br /> O Y H E OL/ CSC. ADDRESS f Cr pH0 f . <br /> Q ADOIIEOs D ► f'110NE f <br /> SUS CONTRACTOR G z. ADOREs9 n �e f� H-77 p`Ho 6 f b3'9 72-76 <br /> IYPE Of"TWPW, ❑NEW WELL ❑RmAcEMEW WETL El MaNnrar NG WELL f ©OTHER <br /> ❑INSTALLATION ❑WELL"OT EM REPAIR ❑CROB9LOHNECT#PAM Q VAPOR EXTRACTIQIJ WELL I ./ <br /> ❑Nth E3 nw b H.P. DEPTH PUMP 9EYT•FT. TIME WATER LEVEL <br /> d <br /> (TV"OF PuMP1 <br /> ❑OUT•OF9ERVICE WELL ❑6EOAIYBICAL WELL f BOIL SOMNO ' v <br /> pJ DESTRUCTIONt ' y <br /> N REX,) B T CONSTRIJCTIO BP CIICAIION <br /> - 11 A <br /> i�,F�•�OID -wAL ❑OPEN SOTTOU btA.OF WELL EXCAVATION DIA.OF CONDUCTOR CAROM p <br /> 'LJ DOMEOTICIMVAYE ❑GRAVEL <br /> PACKISRE TYPE OF CA9lNOlOTEFLO-JC DIA.OT WELL CASINO D <br /> 1❑PUBLICIMUMCIPAL 11 DRIVEN DEPTH OF OROUT SEAL SPECIFICATION R <br /> ' lLl OWOATIONfAO ❑OTHER GROUT REAL INSTALLED BY 0FIDUT SMNb HAMS O E <br /> P-'PAOMTORINO SHOUT BEAL PUMPED:❑Yw ❑H. CONCIIETE PEbEBTAI eY ORRLER:❑Yr. [IN. S <br /> IA-0-- LOCKING CIKOITR BOXMIOVE PIPE S <br /> IPROPOfEO CONOTFIVCTIONIONLUN0 NLETIIOO: MUD ROTARY ADI ROTARY AUGER CABLE OTHER . <br /> 11 NE�BY CERTIFY THAT 1 HAVE PREPARED THIO APPLI��L?C <br /> �� THAT THE WORK WLL BE DONE M ACCORDANCE WRIT OMI JOADU H COUNTY OMMANCE9.STATE LAVA•AND NULFS AND <br /> REGULATIONS OF THE BAN JOAOUM COUNTY.ROUE ENOEO AOEW'e MONATURE CERTIFIED TNT FOLLOWDNGI 7 CERTIFY THAT IN THE PFFIfOI1MATICE OF TTIE VVQ K PORWTGCN <br /> THIS IM"le 199M ,I SHALL NOT EMPLOY PER wORIOAAN'I COMPBHfATION LAWN OF CALIFORNIA.'COWRACTOR•*HNBNO OR BTA4CHTTIACTMO BIGHATUM CERTIFTED <br /> THE FOLLOWING; '1 CERTIFY THAT M THE OF TIIWMIW FOR WNICH TNIB PERMR IN 10"0.1 @HALL EMPLOY PEROONO BUWtCT TO WORWAANY COMPFNOATION LAWS OP <br /> CALIFORNIA.' THS APMMAR? 74 M ADVANCE FOR ALL REGUMin NIS► A 1 T 17041 IMJM B. COAIRLFT WINO AT LOWER AREA PROVIDED <br /> "-w X rnN <br /> PLOT PLAN Ith,-to%9*1 9"* •to <br /> I.NAMES OF STREETB OR ROADS KAMM TO OR ROVNOINO THE TTIMEMY. S. LOCATION OF"DUN SEWAGE INGIM AL OYBTEM OR PROPOSED <br /> 1.OUTLINE OF THE PIIOPMtY.OIVMG DDAENMONB AND NOATN OIRRCTION. EXPANSION OF IMAGE bIBPOBAL 9YOTEMO. <br /> ]• DIMENBIONEO OVTLIHFB AND LOCATION Of ALL EXI@TMO AND PROPOSED B.LOCATION OF WELLS V4"Ml RADIUS OF ONE HUNDRED FIFTY FT. <br /> MRUCTIIR@.INCLVDRM COVERED AREAS OUCH AS PATNOO.DRIVEWAYS.AND WALK& ON THE PROPERTY OM1 ADJONIINO PWPERFY. <br /> ....:......:...... ....C.....;......:............. <br /> ...-. <br /> .. '......'..-.E.....E.....'.. <br /> :.....i.....a........................ .....5..... <br /> E......!...... <br /> ? i - <br /> t. .y......5..,...d.. s ?...i.... .... S <br /> t......:.. t......i......n.... <br /> - ; <br /> I <br /> .�......a......:......2-,.....t... , ..:......t..._._�..-,_. <br /> .. ...: ...:......E.....p...,.:.,. <br /> v. <br /> ... ...,,E ..;... _.._ <br /> ......i..-i......}... ... .... -.... <br /> - <br /> ,.i.....,b. .i......i.. <br /> :......:......:... .i...,. ..i... <br /> .., E.. . .....E................i......E..... .. <br /> < <br /> >...........:.....�... ,..... <br /> ,..,.... <br /> ,.... <br /> ......,.. ... E ...E � E <br /> DlPARTMENT USE ONLY <br /> Apps-"on A...p,md eT At- <br /> ot FN-p I rp:e,lpn DT bm- <br /> Owen,aeMn kwp.ellnn 07 bplp . <br /> ACCOURTIRO ONLY- AID! TAC! <br /> MI CODER FEE INFO AM 111'UT PI A MD C fCABN RECEn".EV DATE pfy"I'll PINCE REQUEST NUASEN INVOICE <br /> 4-. <br /> d 3 0 <br />