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I <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER VENUUEE,,S200CKTON,CA 95202 JAN 19 2000 <br /> NON•REFUNDAILE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IONSTRUCPkl-1.TR�S-IbI �NIYI MENTAL HEALTH{ <br /> APEICATON I$HERE BY MADE TO THE SAH JOAOMI COIMTY FOR A PERMIT TO CONSTRUCT ANpgR MITKI THE WOR!DESCRIBED.TIIII AITLICAigN IB MAD(IN f.OMP1ANC YII I <br /> JOAWN COUNTY DEVELOPMENT TITLE,CHAPTER e-1115.7 AND TIE/ITFA-NDARDS OF BAN IOAOUNI COUNTY PUBLICIIEALIN SERVICE!.ENVIRONMENTAL HEALTH OMBIOH. <br /> JOG AODRESwR A l J'/'f7 f,I Sf h/dd ACdd l�Q /r'{L„/1/(/ CITY JI//Iac A PARCEL IUFJAPN# <br /> oWNFA'■NAM( /"/1/2 C'N/ZL % /jC•/Sst ( L/n ,I L;fI l �✓/I�IMl--HO•/.k-')(�%U�S Si7,Ci/EyJI'{, /)'nioriEF,`' r , +- 1lC I <br /> cowR ToR U'�k./ li/!IL jI/11LL//J✓ ADDREIS ,JGI,N.'r-X SI X.1 V"'t"(� I'71 ''•/� .1 n*ioi14E. <br /> -IRS CONTRACTOR ADOIESE LJCI PGNEF <br /> TYPE OF WELITVM,, ❑NEW w[LL ❑REPLACEMENT Will O Mo—PING WELL l ❑OTHER <br /> ❑NRNIATION ❑WELL-YET EM REPAIR ❑CPOS$CONWCT REPAIR ❑VAPOR EXTRACTION WELL I <br /> HYPE OF PUMP <br /> 1:1N.,.❑P-. H.P, DEPTH PIMP GET FT. FIRST WATER LEVEL O <br /> — <br /> ❑OUT-OF-nRVICF WELL ❑OEOPI/YIICAL WELL/ ❑ SOIL BORING S <br /> ❑DESTRUCTION: <br /> IN ENDED U.E TYPE OF WFLL SON.TRUCTIGN SPECIFICATIONS A <br /> ❑INUU/TRIK ❑OPENBOROM DIA•OF WELL EXCAVATION J DIA.OF CONDUCTOR CASINO -+//1 0 <br /> ❑DOMEITICTRIVATE ❑GRAVEL PACK/SIZE / TYPE OF CAIRN0/STEELRVC i vr, OA.OF WELL CASINO J" 0 <br /> 1:1P1SIlCNVHN:FK ❑ORIVEN DEPTH OF OPOUT EEKBART SPECIFICATION <br /> ❑SWGATIUNIAO ❑OTHER GROUTEEµNSTALLEDGV I)l/ILC IFIL OROUT BRAND NAME JVrLA-6 <br /> MONITORING /T L� GROUT MAL PUMPED:❑Y- ❑N. CONCRETE PEDESTALGY DWLLER:❑V- ❑IN S <br /> A-.DEPTHLOCKING CHENER SOXIFTOW PIPE '( S <br /> TOPOIED CONGMUCTIONIDRILIINO METHOD:MUD NOTARY AIR PXITAIR' AUGER CABLE OTHFR <br /> I HE<E-Y CFRTFY THAT I HAVE PREPARED THE APKKATION AFRO THAT THE WOW WILL GE DOFF N ACCORDANCE WITH IANJOAOUN COUNTY ORDINANCES,STATE LAW-,AND RULES ANO <br /> MOVLATIONS OF THE SAN JOAGUN COUNTY.NOME OWNER OR LICEN-ED AGENT'S SIGNATURE CERTIFIES THE FOLLOWh:'1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR W.IICII <br /> THE PERMIT IN 19 0.1 MIALL NOT EMPLOY PENONG IRMACT 70 WORKMAN'G COMPVFIATON LAW'S OF CALIFORNIA.'CONTRACTOR'$HIRING OR-UGtDNTMCTNG SIGNATURE Cf NISI <br /> TIE FOLLOWING: -1 CERTIFY THAT N TE PERFORMANCE OF THE WORK FOR WHICH TME PERMIT 16 IE-USD,1 SHALL EMPLOY PER-ON/SUWECT TO WORWAN'S COMPDN.ATGN LAW$OF <br /> CALIFORIIA.'THE APPN,,:s!ANT MUST CALL 24 00NY N/�✓NRCG FOR ALL NOWNED I�NS/Pp110N AT IiMI MM.M]S,COMPLETE DRAWING AT LOWER AREA P OVIOED. <br /> no T PLAN lo'-N M.W S.Y. I 9' <br /> RT <br /> 1.NAME-OF IFFEETS OR ROADS WAKIT TO OR POUNDINGTHE PROPEY, /,LOCATION OF/IOUlE*MAO(DISI'OSAL IY/TEM OR P MJIU <br /> E.OUTLENE OF THE PROPERTY,OIL'NG OMENMNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOIAL SY-TEMS. <br /> S.OMENEIONED OWUNE.K LOCATION OF ALL EXISTING AND PIDFOEED I,LOCATION OF WFLLS WrTWN RADNI OF ONE HUNDRED FIFTY R. <br /> STRUCTURE.INCLUDING COVERED AREAUE BIRCH AN PATIOS,DRIVEWAYS,MID WALES, ON THE PROPERTY OR ADJOININO PROPERTY. <br /> i._..l. VIC,Ju <br /> • <br /> MW-y aoc�AL.� <br /> r-ttiJ-I <br /> .Mw_3 <br /> NLJ1?LsIrc Ncmu!'—L4, <br /> / DVMTMpT USE ONLY / ! J' I' <br /> AP.$...—A..-W er �% I l / � G G�. ow �I /% An <br /> M G o•S I C <br /> ACCOUNTNO ONLY: AOl PACI <br /> PE COO" FEE INTO AMOUNT RWTTED CHECK/ICASH AECINMAY DATE P9►ATISDRVICF RFDUER NUMBER INVOICE <br /> ZY D -77,70—1 <br /> PLO HQ&M Sere.•Envlro.173(1/97) <br />