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NPPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENYIAONMENTAL HEALTH DIVISION <br /> P O BOX 388,304 EAST WEBER AVENUE STOCKTON CA V-201-3W <br /> (2091 469 3420 <br /> NON NEFUNDABtE PERMIT EXPIRES 1 YEAR FROM DATE 13SUED <br /> ILfRIPMIf In Tr`IFCAIfsI <br /> AT%1N IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FORA RE .IIT TO CONSTRUCT ANOIOR W6TALL THE WOMC DESS RISED THIS APPLICATION Ib MADE IN COMPOANCE WITH SAN <br /> AWIN COUNTY DEVELOEMEM TITLE CHAPTER B 1115 3 AND THE STANDARDS OF SAN JOAQUIN COUN'"PPUBLIC HEALTH SERVICES ENVIRONMEHTA4 HEALTH DIVISION <br /> � <br /> JOB AbORESSMA APN/ / !) Iti_rni 1Sr{. �11� rFi r _1 K—S_�CrtY^1 'F LI / T.!�^ PARCEL aTEIAFtI/ <br /> OWNER S NAME L-ti= /Y/e.4,k_ _ADDRESS!^ h I.. PTWHE � <br /> l / ✓i fJ,,l.1—+.Cf <br /> CONTRACTOR ! � )r !7 - f ADDRESS J /„ / r1 JY�Lx1 / SNE 1;9If�'�1 l7F <br /> sue CONTMCTOR / ••� tJ !// ! . / ADDRESS�.7+ J • /PHONE `/ <br /> TY OF MP ❑ NEW WELL ❑1-K RFPLACEMEW WELL 1�MONITORING 1NELL/ �1. IE ❑ OTHER II <br /> ❑INSTALLATION 0 WELL SYSTEM REPAIR L7 CRON"ONNECT REPAIR 0 VAPOR EXTRACTION WELL IF J 7 <br /> ❑N«.❑Pe.h H P DEPTH RIMP SET_" FrRST WATER LEVEL O i77i <br /> i <br /> ITYPE OF PVMPI <br /> �j ❑OVfbF•/SERVICE WELL ❑OEOPHYi1CAL WELL♦ ❑ SOIL BORING S <br /> INTENDED UK[ TYPE OF WCLL CONE TRLCTIOrN•PECIFiCA]IONK '� <br /> r--� I I <br /> W INDUSTRIAL ❑OPEN BOTTOM DIA OF WTLL EKCAVATIDN ! DIA OF CONDUCTOR CASINO D <br /> ❑DOMESTI MRIVATE U GRAVEL PACKrnIE TYPE OF CASINGINTFEUPVC .7 f D1A OF WELL CASINO O <br /> �❑-1 PUBLIRM <br /> CLINICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> LJ MMOATIONIAO ❑OTHER p GROUT SEAL INBTALUD BYGROUT BRAND NAME F <br /> 1-1 RNCl <br /> MONO <br /> NG GROUT SEAL PUMPED U Yr 6No CONCRETE PEDESTAL BY ONtLER.❑Yr ❑N. S <br /> APPROX DEP 14 EDMINO CHESTER BO%MOVE RPE S 3` <br /> PROPOSED CON11TMICTIONIOMWNO MEr HOD MUD ROTARY AIR]ROTARY AUGER CABLE OTHER I <br /> L <br /> I <br /> 1 HERERY CERTIFY THAT 1 HAVE PREPARED THM APPLICATION AND THAT THE YrOM[WILL BE DONE IN ACCOROANCE WITH SAN JOAOVAH COUNTY ON31MANCEN RATE LAWS AND RULER ANO <br /> P.EOLMTIONf OF THE SAN JOAQUIN COUNTY HOME OWNER OR LICENSED AGENT S SIGNATURE CERTIFIES THE FOLLOW HO I CERTIFY THAT IN THE PERI ORMANCE OF THE WORK POR WHICH <br /> THIS PERMIT IS ISSUED I BHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN S COMPSNSATION LAWS OF CALIFORNIA CONTMCToR 5 HIRING DR SUB-CONTRACTING MNATLME CERTIFIES <br /> THE FOLLOWING 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS VFRMIT IS ISSUED I ,ALL EMPLOY PEMWNS SUBJECT TO WORIGAAM S COMP[Nf AYTON LAWS OF <br /> CAUFORFMA..RHE APPLCANTJAWT CAtl ai IbURS IN ADVANCE FOR ALL RFOCMIFD ENSFSCT10144 AT E=WI AB4I s Zl COMPLPETE DR WHO AT tOWER AREA FRONDED / <br /> I ( / f7'r/ <br /> slwrd X / ( M17/ _ TNI. X!(r / 1 IH1.� � ( - <br /> J I <br /> PLOT KLAN Wrw 1.B .I Sed. to I <br /> 1 NAMES OF STTELTB OR ROADS NEAREST TO OR b0UND1NO THE rNOPEFITY S LOCATION OF HOURE S WAGE D4MPOBAL fYSTEM OR PROPOSED <br /> 2 OUTLINE OF THE PROPERTY DIMING DIMENSIO1fi AND NORTH DIRECTION EXPANSION OF SEWAGE OISFN]BAL MYiTEMf <br /> DIMENSIONED OUTUNFS AND LOCATION OF ALL EXLSTINO AND PROPOSED S LOCATION OF WELLS WITHIN RADRIS OF ONE HUNOREO FIFTY FT <br /> STRUCTURES INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALKS ON THE PROPETTTY OR ADJOIMNO PRDPENTY <br /> 1 <br /> _ DEPARTMMT WE ONLY <br /> G...r.P.eIY+I B, r � G.I M.r Ir�.nNn BT b•1• <br /> O.+IRS—IR—N-by D.I• <br /> C—, <br /> ACCOLMTNO ONLY AID/ FACT <br /> K CODERFR IMO AAKOUHT RONY7ED CM[C KAfC AKN ITEC QVED PT DATE rp,,M,T,.Q cf REOUt1T MEMBER INVOICE <br /> I <br />