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APPLICATION FOR WELLIPUMP PERMIT 46 <br /> SAN JOAQUIN COUNTY PUBLIC KEALTH SERVICES <br /> ENVIRONMENTAL NEALT. IVISION <br /> P.O. B®X EAST WEBER AVENUE,s . ,LTC TV-A -'T`IT Sn <br /> (2091408-3420 ', ~ <br /> IRONhIENIV,IM,NUI-11 I)I''.'ISION <br /> NDN•REFUNDABLE PERMIT EXPIRE8 1NTUF101111 @ATE IBSU �i � � _ �` <br /> tComplgts to Yr(pAPPLICATKIN 1811E1 BY MAt>E TO THE BAN JOAOUIN COUNTY f0R A hERMIi TO CONSTRUCT AFIF/OTHE Wow DEBCIIeEV.THIS APPLICATION IB MADE IN COMPLIANCE WRH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1 116.3 AND YN�BTAN-¢Am�uS O�8AN ItGU1N COUNTY PIIBLK;HEALTH SERVICES,ENVIRONMENTAL HEALTH Mvifflom. <br /> JOB AODRE88/ORAMdI_ F1'lV1Gd1 �iLMYlT7 LQnd�t�l�� 'j'�jMppm1lh® (fid, cm., gS+tock•4-oh PARCEl81AE/AEM1! 10-6 "® <br /> OWNEn's NAME 1'f6t LFr a'foo- -0 DPW �Y AbbN96-1475 N. MdomAa <br /> 1a® rt m937'S z <br /> CONTRACTOR CAM Tress 'y- � Mc Ke 7-•n r � ��, 5'�300 <br /> PIlow'Si am-2.)M <br /> su$coNTRActon W�S�er'n S�►'ta¢d .�Mfi� '-finr r*' Brix TGe <br /> ADonEgB�g cam, A LICNC,23 NE#:3(L;- ?7 <br /> 1YPE OF WEL-4 MP: ❑NEW WELL ❑ REPLACEMENT WELL 59 MON"oeum WELL#-tijy= A N 9 <br /> W«1® OTHER <br /> DtcliCnfccl ® INSTALLATION ❑WELL SYSTEM REPAIR 11CROSS-CONNECTREPAIR <br /> l 144der FULT ElNew❑Rtgral, H.P. MW-PA (oA w11 VAPOR EXTRACTION WELL# J <br /> (TYPE OF PUMPI ` DEPTH PUMP SET El <br /> y �,4 FIRST WATER LEVEL O <br /> ❑OUT-Or-SERvK:E WELL ❑ GEOPHYSICAL WELL 0 <br /> M�"9$a � 11 gory BORiNO <br /> 13 B <br /> bEBTRUCTiON• <br /> NTENbER VSE TYPE OF CO STRUCTIQN SPECIFICATRONg <br /> ❑ <br /> INDUSTRIAL ❑q OPEN BOTTOM DIA.OF WELL EXCAVATION (_Q-(('{�. DIA.OF CONDUCTOR CASING aloe. A <br /> ❑ DOMESTIC/PBVAtE 101 GRAVEL PACK/SIZE 6 TYPE OF CABIIG/BiEEI/F'VC nn <br /> 2/L Mw— <br /> _F VIA.OF WELL CASING 4"'In[, O <br /> ❑ PIBUC/MUlN!CMAU. ®OMVEN Lon ee cLr- OEPTHOFOM IT BEAL_#4 A, O ^' -1 S <br /> P <br /> E <br /> CI <br /> FICATION aIle i�,,�,, I� <br /> ❑ IRRroATroN/AO ❑OTHER �T�_.172Y1{onit�./ceftj n�- � <br /> GROUT SEAL INSTALLED By -a((g.r' OMOUT BRAND NAME <br /> 4d1 MONITORING pr� E <br /> (AW-SA, ctA, *A LIQ'R-- GROUT SEAL PUMPED-191 Yea ❑Nq �'MiP@^. CONCRETE PEDEBTAL BY DRILEn:❑Yea Elm. g <br /> APPROX.bEPTN_(V� LOCKING CHEgTEn BOXI#TOVe PIPE 'T' S Gomlai@LiovN w I% Lek king CQI' <br /> PROPOSED CONSTRUCTION/ LUNG METHOD: MUD ROTARY $ <br /> Ala ROTARY AUOER�_CAg1$ OTHER <br /> I HE9EBY CERTIFY THAT I I/AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE W1tH SAN JOAOUIN COUNTY ORDINANCES,STATE IAWB,AND RULEB AND <br /> REGULATIONS OF T/IE BAN JOAQUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY 114AT IN THE PERronMANCE OF THE WORK FOR WIICtI <br /> TIS"PERMIT IS ISSUED,1814ALL MOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALLA A,' CONTRACTOR'S HIRING OR SUB-CONTRACTING S1ONAtURE CERTIFIES <br /> THE FOLLOWING: •1 CERTIFY THAT IN THE PERFOAMANCE OF THE WORK FOR WIBCN THIS PEMW to IsgUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN's COM NSATION LAWS of <br /> CALIFORNIA.' THE APPLICANT MUSALL ♦NOUR41 IN ADVANCE FOR ALL Avotmn b INBP TIONS AT 1:1001 400-342S. COMPLETE GRA AT LOWER AREA PROVIDED. <br /> Blened X- �j�(T - TOO <br /> PLOT PLAN(Drew to Beale►coal" 'to <br /> 1. NAMES OF StP <br /> REET8 OR ROADS NEAREST TO OR B01MOOM THE ROPERTY, <br /> 2. OUTLINE OF TILE P10PERTY,QIVINO OtMERMHO AND NORTH DMECTroEXPANSION OF SEWAN. 4• LOCATION OF HOUSE EWA SEWAGE DISPOSAL SYSTEM OR PIGPOSEb <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND ProPOsEd GE OISPOBAL SYSTEMS. <br /> STRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION OF WELL$W"MN"Us OF ONE HUNDRED rIFTy FT <br /> ON THE PROPERTY OR ADJOINING P10PEntY. <br /> L <br /> Sx <br /> 'French CampHw- <br /> Laod4ij SA <br /> , <br /> " MSV"'�� �.,,�-,�•,.r4��+�N's <br /> ��►-9g JAN 2 8 19j1 <br /> t <br /> Mut`(aAAN ji.A01,j1N CGUNT'f <br /> �-�BLIC PHEALTH SERVICES <br /> YIRIC v <br /> r <br /> �� r��AL HEAL:- iv NOR <br /> . ............................................... <br /> DEPARTMENT use ONLY <br /> Apploation Aeoepted By { a 8 �"f <br /> —7 bees / At"_ <br /> GfetM b,speertion By note Pump Mepeetlen By <br /> Gate <br /> Destrtnllan Irxn�:linn Ry <br /> // Date <br /> Cemmeme: C/'M1 �C/� r, <br /> /� Len 4.+0►�C ae,fr// (/ a Ia <br /> EtG CvtirA�n qh i oS <br /> C)d- r v P �iT/fy �cs7 d t�t�ih;q f-' cr Ja <br /> �an t Rin a .etA Itw qP y ¢te <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CFIEC /CASH RECEDED BY DATE <br /> PERMITIBERVICE REQUEST NUMIBER INVOICE <br /> 035 <br /> O <br /> a b3a4.3 <br /> PUD.H e1tFi Serv.- nv o.�7 (3/96 �C <br />