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APPLICATION FOR WELLIPUMP PERMIT <br /> AN JOAOUIN COUNTY PUBLIC HEALTH SER <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST wr=BER AVENUE, mcKroN, CA 85201388 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT 14 <br /> �I <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PEIIMR TO CONSTRUCT AND/OR NSTALL THE WORK DESCRISEO.THIS APPLICATION IS MADE IN COMPLIANCE WITH SA <br /> JOAQUIN COUNTY DEVELOPMENT TIRE,CNAPTER&111 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY MOM HEALTH SERNCEB.ENVIRONMENTAL HEALTH DINSION. <br /> JOB ADDREDSVOR APPN 23569 South Santa Fe Road qn. Riverbank, CA PARCk1 SRE/AYFIP <br /> OWNER•cNAME Durhim Saleh Ali ADp1E8&_ Riverbank. CA 95467 PHOW0209-863-923. <br /> CONTRACTOR Arrowhead Consultants ,SSSModesto, CA LIC& PHONE#2 09-5 7 4-0� <br /> SUS CONTRACTOR Pierson Drng Amy 7816 Apple Blossom UCE 614108 PHONEE7o7-823-' <br /> TYPE OF WNLq/MP. ❑ NEW WELL ❑ RERACEMEM wuE ❑ MO. cnw WELL E 13OTHER <br /> M NSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRUIIBCONNECT REPNM ❑ vAPOR EXTRACTION WELL I <br /> fTYPE OF PUMP{ <br /> 10N.13Awm N.P. DEPTH PUMP BET FT. FRUIT WATER LEVEL <br /> T� <br /> 13ELT.OUT-0E-evwICE W13GEOPHYSICAL WELL F Lq BOk Bomm B <br /> ❑DEBIRUGTION: <br /> INTENDED USE T�YPE OF WELL CONSTRUCTION fPECIiCATbMt A <br /> IN <br /> ❑ DU1 <br /> STRIAL 3 OPPJ1 BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACIVSRE TYPE OF CASINO/STEELIPVC DIA.OF WELL CASINO D <br /> ❑ RIB WUNICNAL ❑DRVEN DEPTH OF GROLR REAL SPECIFICATION A <br /> ❑ IMOATION/AO ❑OTHER OPOUT SEAL NSTAELED SY Pierson Dr1111n�prowaRANDNAME E <br /> ❑ MONITORING _'35 I GROUT SEAL PUMPED: toy. ❑N. CONCRETE PEDESTAL BY DRLLRt❑rw ❑w S <br /> APPROX.DEPTH LOCKNO CHESTER W STOVE RPE S <br /> PROPOSED CON&TRUCTIONIWSLUN4 METHOD: MUD ROTARY AIR ROTARY AUGER h!' CABLE OTHER <br /> 1 HERESY CERTIFY THAT 1 HAVE PREPAHAD TMS APPLICATION AND THAT THE NOW,WILL BE DONE IN ACCORDANCE WITH SA:JOAQUIN COUNTY OVE NANCE6,STATE LAMS,AND RULES ANL <br /> REGULATIONS OF THE SNI JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CER IMS THE FOLLOWING:I CERTIFY THAT N THE PERFORMANCE OF THE NOR(FOR WHICI <br /> THIS PERMIT IB ISSUED,I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN•&COMPENSATION LAPIS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING MNATVI E CERTD1E, <br /> THE FOLLOWING: '1 CEKTIFYTHAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB RSUED.1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'#CDMPEI&ATON LAWS Oi <br /> CALIFORNIA*, �L �THE APPLICANT Ui/PALL 2 HOUR&N ADVANCE FOR ALL REWMED NSPICTIONS AT t3M1 Mesta. COMPLETE g WINO AT LOWER AREA PROVIDED. <br /> ftp x (.C-C .-_. TM, Owner D.., 12-17-97 <br /> POT PLAN 0.t.BPWI <br /> I. NAMES OF STREETS OR ADADS NEAREST TO OR BOUNDKNO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,UNMO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISnNO AND PROPOSED S. LOCATION OF WELLS WITHIN KMRUB OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> ... .: ..:'.... .... .. �...: .� <br /> ..........:......:._......................a..... <br /> ii ' i ' i.....:.._.......:......i......:...... <br /> .. <br /> ... MAP ON BACK ..... ,.. <br /> D®ARTNI M USE ONLY <br /> a'.I..wb Br t>~. t1.,,P tr+o.e.l.,,Br D•1. <br /> IM.t..ctlon In.P.a.l.n By <br /> d.. <br /> ACCOUNTINO ONLY: AIRF FACT <br /> "cam FEEINFO AAOUNTRIAW.,. CHEC"n"N REcqvIED SY DAT[ PANRTI#FRVICF REOVF#T NIEH#W INVOICE <br /> 356 S2fs' <br />