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APPLICATION FDA WELQPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O, BOX M.904 EAST WESER AVENUE,STOCKI'ON, CA 95201388 (2091489-3420 RON-REFUNDABLE PEAMIT EXPIRFS I YEARfreFROM DAiE ISSU O APPL)CAT;ON 1S HERE RY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT phis I A"(WOR INSTALL.THE WOPK DESCRIBED.THIS APMCATION IS MADE IN JOAQUIN COUNTY DEVELOPMENT(T TITLE,CHATTER 8.1 11 E.3 AND THE STANDARDS OF BAN JOAGON COUNTY PUBLIC HEALTH SERVICES,UMF40NPAENTAL HEALTH VIVISIONµCE WITH SA JOS ADVFESM)R AIM/ "/ Cm / /Q Ail /� -�'� ----+^^-�.-^��`�-`-�-��[�7 PARCEL SQE/Ai'Nr ONTiER'S NAMES -h A f I//P/'� (" ADDRESS ckn a — C� 9 VONTlucrOR1� 4 f++or+E r . �).PI L/V 4 _ACOREsa ucr r �pl�'p�2Qf�-PHONE r�� 81M CONTRACTOR ADORE99 J� 'fj �7 I'FIONE/ PE OR WFLURRAP: {il NEW WELL ❑REPLACEMENT WELL IDMONITORINGMONITORING WELL F ❑OT — ,(LT.jJ.,INSTALLATION ❑WELL SYSTEM REPAIR ❑ CR068 CONNECT REPAIR ❑VAPOR E:-TRACTION WELL r Nr N.-Pum (TYPE CF P) aP.'I H.P. DEPTH PUMP LET/ '7 FT. FIRST WAFER LEVEL f ❑OUT-0SIC OUT-0F-SERVICE WELL ❑GEOPHYSICAL WELL f 13SOlL BORING S INTENDED U46ly yRE OF WELL CON&MM MJN GP IHCATION 0 INDUSTIdlRIAL OISN BOTTOMA DIA.OF MIELL EXCAVATION— DIA.OF CONDUCTOR CABMta W MESTICS>RIVATE ❑GRAVEL PACK/31. D I-T TYPE OF CASINOISTEEUPVC DIA.OF WELL CASING_ _ ❑PIJ QATI VNICD`AL ❑OTKEM DEPRN OF GROUT SEAL 2i'i cL SPECIFICATION r!7 L NbBGATION7AG Cl OTNEq / c R GROUT SEAL INSTALLED BY t ); C OPAUT BRAND NAME_/ A iF� aC -.t R� C SPECIFICATION- MONITORING DPA UT 6EA1 PV MPEG:L,�Yw ❑No CONCRETE PEDESTAL BY DM1ER:❑Vw ON. S AF•PROX.OEIT H_ -_ LOCKING CHESTER BOX/8T O VE PIPE M o porED CON[TRUCTICN,'DHWNO METHOD: MUD ROTAAY 5� 8 _ AIR ROTARY AUGER_ CARIE_-fA--OTNEII I HEREBY CERY WY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOPo(WR.L SE DONE IN ACCORDANCE MTH BAN JOADUN CO.—oRDINANC[S,8TATE LAWS,ANb RVIES AM REOVLATIONG OF THE cµJOAQUIN COUNTY. NOME OWNER OR LICENSED ADENT'S SIGNATURE CERTIFIER THE FOLLOVAM:'I CERTIFY THAT IN THE PEAFOFU.WCE OF THE WOK(FOR WHK1 l THIS PERM IT IS ISSUED.I WALL NOT FMFLOY PERSONS SUBJECT TO WORKMAN'&COMP4NFATION LAWS OF C/WFORNIA.'CONTRACTOR'S MMNG OR SVS{pMN E OFGSIONATLR 1"'OR FlE CALTHE POLLOWMq: 'I CERTIFY THAT IN THE PEFiFO M1MANCE Of THE WU°K FOR YN11CH THIS FERRARI IR IS SV EU,I"ALL EMPLOY PERSONS BUSJECT TO WORKMAN'S COMP[NSATION LAWS O CAUFORMA.- AYRUCANT .T CALL 2A IIOIAI.IN ADVANCE MR ALL M"Fo IN.PSCT,,N.AT F7"1 A.S3.23.COMrU7E DRAWING AT LOWER ATEA PROVIDED. eID�,.I x PLOT KAN IQ,-Ie a..I.l BR.1. •Io _. on. I. HALESOr STREETS OR ROADS NEAPERT TO OR SOUNOINO THE%gPEPIT/. I. OUTUNE OF THE PROPERTY,atVNO DIMENSIONS AND NORTH bIRECTPON, 4. LOCATION OF HOUSE REWAOE DISPOSAL SYSTEM OR pnOpO$ED 3.DIMENSIONEO OUTLINEF AND LOCATION DF ALL EXISTING AND PROPOSED EXPANSION OF REWAOE DIRPO2kL 4,yMMR. STRUCTURE3,INCLUDING COVERED AREAS SUCH A8 PATIOS,DFIVEWAYB,AND WALKS. G. LOCATION OF WFLLo WTTHI14 RADIV.OF ONE HUNOREO FIFTY FT. ON THE PROPERTY OR ADJOINING PROFRTY. ...I. ....:.. ......y...... I .. ... .... z..........,. .. i i.. : • eJ j :. •i :.. t.... _. •.. .b. ..... ..... KA I 77, .. ... ....i.....1 .:.....:... i DEPARTMENT USE ONLY Appli-k,A..pl.d Br-_ D.I. _A- OIDIA I- nq �` PoclloD er= D.I, ar pwln,ell?R ID.PlatiaR BT I o.I. - � C<wnmerNl:_ -- V ACOT.UNTINO ONLY: AID/ EACI - � LD '/E CODE. FEE INFO AMOUNT REMITTED N[C MA➢H RECEIVED NY DATE REM ITIVERVICB AEOUFxr NUMam R/VOICG � D o SCD