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FOR WELLIPUMP PERMIT <br /> CIANJOAQUIN CD APPLICATION NTY PUBLIC HEALTH SERVICW <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304'EAST WEBER AVENUE[ STOCKTON► CA g52Qi-388 ? <br /> P.O.BOX 988, t209} 4es-3420 <br /> NON-REFUNDABLE PERMIT <br /> ANDIOR INS) THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> . COUNTY FOR A pE M TO CONSTRUCT <br /> AOUIN COUNTY PUBLIC HEALTH SERVIC <br /> E9 ENVIRONMENTAL HEALTH IWAS10N. <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAWN <br /> I s.3 AND E STANDARDS �+ 1 L. 1 _ PARCEL SIZE.IAPN! <br /> JOAGUIN COUNTY DEVELOPMENT TITLE.CRAFTER <br /> CRY <br /> - PHONE <br /> JOB ADDRESSIOR APN/ � S <br /> ADDRESS PHONE <br /> I.l— <br /> OWNER'S NAME ' <br /> . X PHONE: <br /> CONTRACTOR ADORES . <br /> SUS CONTRACTOR <br /> ❑ STREP r <br /> [3REPLACEMENTWELL ONITORING WELLE���• E <br /> OF:WELLIPUMP: NEW WELL VAPOR EXTRACTION WELL <br /> TYK o <br /> SYSTEM REPAIR CRO88{pNNECTREPAIR <br /> fi Q <br /> STALLATION ❑ WELL - �• FIRST WATER LEVEL . <br /> DEPTH PUMP SET r <br /> New❑Rapolr H.P. - 8 <br /> RYPE Of PUMP) ❑ 06PWIMAL WELL>r ❑ 661E BORING <br /> ❑ OUT-OF-SERVICE WELL <br /> �.^-.--�.r=:..,. .,�'., *e.+:e"'►� .":.+��, �-_._� - <br /> ❑DESTRUCTION: <br /> • A <br /> INTENDED UEE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> l DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> �. ❑ INDUSTRIAL ❑OPEN BOTTOM '6 - <br /> TYPE OF CASINOISTEEI.IPVC P Y G DIA.OF WELL CASINO U <br /> ❑ DGMESTIClPWVATE RAVEL PAt'2U8{ZE� 5�c � '— _ <br /> rn' R <br /> ❑ PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL, �� SPECIFICATION - <br /> .7 �.�w❑y�tt tRWOATKINIAO ❑OTHER - GROUT SEAL INSTALLED BY GROUT BRAND NAME 1° .emn 1 k F <br /> Yf MONITORING GROUT SEAL PUMPED: Y. El No CONCRETE PEDESTAL BY DWLLER:�V� ON. S <br /> . l`APNtO%.DEPTH LOCKING C//HE__STE%SOXISTOVE PIPE�(�[.(I')IE (3ox S <br /> PROPOSED AIR METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND TRAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES;AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORIGNAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-COMPACTING SIGNATURE CERTIFIES <br /> E� THE FOLLOWI '!CERTIFY THA IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORIGMAW&COMPMSATLON LAWS OF <br /> CALIFORNIA.• CANT T CALL 24 HOURS IN ADVANCE FOR ALL REOIAR TIONS A(T�-1r2(0�p)4p4{23. COMRE I DRAWING AT LOWER AREA V1DEO. <br /> Sol X TItieIe f1^ 5 lJ Y Dote <br /> Fs PLOT RAN(Drew to Goal Serle `to <br /> L. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. r 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. _ EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY ll <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK8. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> .. .......... <br /> R <br /> -MAP--CN <br /> DLEPARTNIEN'T UTE ONLY 7 <br /> - Applleetlen Aaoepted By Data C—T� "•' <br /> Ares <br /> Grout Iropeetlen BY Date Pttrnp htepeetbn By Dote <br /> DeetrUetlen lr*peotlen BY ti Date <br /> Z� ACCOUNTING ONLY: AFDi FAC# ' <br /> .3 PE CODES FEE INFO AMOUNT RDSYIrtTEb CHECKllCABH RECEIVED BY. DATE °PERWITlFBGVICE REOUE>1T Nl1MBFA INVOICE <br /> bio76 <br /> zP <br /> 0 o 73 0 <br />