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L <br /> APPLICATION FOR WELLIPUMP PERMIT '� <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERYL <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388.904 EAST WEBER ANIME S ?MON, CA 9MI-M <br /> (2O9] 460.2420 <br /> NON-REFUNDABLE PERMIT <br /> I I II II <br /> APPLICATION IS HERE BY FADE TO THE BAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SARI <br />{ JOAOURN COUNTY DEVELOP111EmT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,EWARDI'IMENTAL HEALTH DIVISION. ei1 <br /> h e <br /> JOBADDEH�SBOR AP �k r Sam', 6whk.-5b1 W We[�r !��e cm <br /> OwNERI s NAME p,t 54-ou PINONE■ <br /> coNTRAcrGre ie�•Qr,c,: jN1�— S es 98 7 ' IID1Z. p10,Uw\Uc ucE PmNES916-369-'19�f <br /> SUS CONTRACTOR s e c S.u'r► S -�'•'1� �,._ \r1 C _ADDREsa l `I Se sq <br /> LIGG-1 S -b 3/' <br /> TYPE OF WEIlIPVMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONTORNG WELL l ! OTHER In or <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROW CONNECT REPAIR li I ❑ VAPOR EXTRACTION WELL <br /> ii <br /> ❑NRw❑Mw* H.P. DEPTH PUMP SET FT. I ;! FIRST WATER LEVEL O R Ref <br /> TYPE OF PUNIPI \[3 - i <br /> OUF-0F�SE1fVICE WELL E3OEdPF1YBICAL WELL I Il " �-801L SORAJL�ccn ) � 8 <br /> ' ❑DEBTRUCrroN: I; i } <br /> (NTEMDED LOU n/,4 TYPE OF WELL fV CONSTRUCTION SPECIFICATIONS Al II A i <br /> ❑ SNOUSTIIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION II DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTD/PIIVATE ❑GRAVEL PA13L/sw TYPE OF CAIANGlSTEELJPVC II II CIA.OF WELL CASINO D <br /> Q PUsucl MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL �I II SPECIFICATION R <br /> ❑ mmiAT10WAs ❑OTHER GROUT SEAL INSTALLED BY II iG GROUT BRAND NAME E <br /> ❑ MDMTORItNO r7 GROUT SEAL PUMPED: 13Y. ❑Ne CONCRETE PEDESTAL BY DRILLEHL•❑Y.. ❑Ne s <br /> APPROX.VEnM LOCKING CHESTER BOXNwro PIPE s <br /> PROPOSM CONSTRUCT11IN14450111.1.10114 IMETNDD: MUD ROTAK AIR ROTARY AUGER.IG CABLE OTHER r <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAH JOAOIMN COUNTY ORDINANCES,STATE LAWS.ANp RULES AND <br /> REGULATIONS OF THE SAN JDA4111N COUNTY. HOME OWNER OR LICENSED AGENT'S sONATURE CERTIFIES THE FCLLVWINlLi:-1 CERITFY THAT ON THE PERFORMANCE OF THE vwow FOR WHICH..: <br /> THIS PERMIT E ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOMWAAN'S COMFEHSATON LAWS OF CAUFORNIA.- CONTRACTOR'S H1104 OR OUB-CONTRACTING SIGNATURE CEFMFIEB:;'P <br /> THE FOLLGVWNS: -I CERTIFY THAT N THE PERFORMANCE OF THE WOPIK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT YO WOPWAAN's COMPENSATION LANs OFT€1 <br /> 4 CALIFORNIA.' THE APPLICANT MUST CALL 34 HOLM N AfVANCE FOR ALL REOUNII&D INSFICTIONS AT tMI 4=4429. COMPLETE DRAWING AT LOWARE <br /> ER A PROVIDED. of r <br /> shrw X �" TRIM <br /> ,i <br /> i PLOT PLAN Slow to 0 BaN 11 .r •is <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. it 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED °�{3 <br /> S. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTIR DIRECTION. j EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ! <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTHSN RADIUS OF ONE HUNDRED FIFTY FT. k <br /> STRUCTURES.INCLUOING COVERED AREAS SUCH AS PATIOS.DIIVEWAYB ANC WALKS. I� ON'THE PROPERITY OR ADJORNNG PROPERTY <br /> . .:.. :. ,. . :.. .:....: it <br /> MAP ON BAC K ' . <br /> ... ....... : . .......... <br /> : . . l.. . � ` <br /> DEPARTMENT USE ONLY . <br /> AmAostion AooRptrN sY I t. 7 II Dm Ar . Y <br /> Ore1>t MrPeeNen SY oto PL-P Unpeco—BT' it Doto <br /> !II <br /> Do.tructbn 1•rn.atisn By <br /> Date <br /> cm" ml <br /> .II. II l <br /> ACCOUNTING ONLY: AIDE FACT <br /> PE CODES FEE UNFO AMOUNT PA%Wrr= CHECXIICASH REBBVEb SY DATE II. 'PEIOTISERVICE IIEGIIEST NUMSEI INVOICE .T <br />