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0.0LPtIon Imam*. By Dam <br />PAY MENI <br />tirEN VI 1995 <br />SAN ILINA.L1i4,4,.../IN <br />" PLIBUCI1EALTr1 SRV cf:E$. <br />:•tisiviRONMENTAi... . . ... <br />DEPARTMENT U.S ONLY <br />APPaaatlw, Ae1.1. TIT I (it CI iCtH <br />(50.1 bout PLATIp Impaction Sy r•Le--1 Det• <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />13.0, BOX 388.304 EAST WEBER AVENUE, STOCKTON, CA 95201488 <br />(209) 4663420 <br />NOM-REFUNDABLE PERMIT txriRts I TEAR PROM DATE MUM <br />1Coniebh, In TrVita tal <br />APPLJCATION 13 HERE BY MACE TO THE BAN A3AOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE W011( DESCRIBED. THIIIIAPPUCATION IS MADE IN COMPUANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT ETTLE, CHAPTER 3.111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIAONMEN E AL HEALTH DIVISION <br />JOS ADOPEEM/011 APNI &It irAir 1.1 II 5.1—S 'We PARCEL KEEIAP1,1 <br />OWNER'S ?LAME rig af ZS. ./c2.4.1.1.412e.)—. AGOR,SDI/9 9/S— Pi("sniihifte,1241.124-S'fii14,0NE 5-32-414;ile <br />CONTRACTOR A40) 4.11i4t.:<c ADOPEBORa,a1( ucs 46.6u1za_ PHONE Of..79--41b£44 <br />SUS CONTRACTOR AD0Af118 LICS PHONE I <br />TYPI Of WELLI6--'4I"...% <br />fAlhot-/ .4.-4...; 1-6_, <br />0 NEW WELL <br />131 INSTALLATION <br />0 Now13 Repalt <br />0 REPLACEMENT WELL <br />0 WILL SYSTEM REPAIR <br />H.P.ifty140.0, <br />12i_ <br />41.da,/ <br />0 .10 <br />0 OUT-Of-SERVICE WELL <br />0 MONFT011110 WELL / 0 OTHER <br />0 CROSS-CONNECT REPAIR <br />DEPTH PUMP SET al-19 FT, <br />0 VAPOR EXTAACTION WILD <br />' FIRST WATT.. LEVEL 0 (TYPE OF PUMP) <br />0 GEOPHYSICAL WELLS 0 SOIL BORING / <br />0 999.9acrit94, k 4 _ok.ca.d.. AV-A-1-.-,. 1 4 I p... I . Li . 7,,,,pj, ....., . <br />a-, <br />(il A TYPE PATMlatkE1 LI_AL CONSTRUCTOR sildeicAt to ms <br />0 INDUSTRIAL DOPER SOM. <br />121 <br />DTA. Of WELL EXCAVATION TPA. OF CONDUCTOR CASING 0 ,.. <br />TYPE OF CASINTUSTFEL/PVC DIP. OF WELL CASINO le A DOMESTIC/PRIVATE 0 GRAVEL PACTURZE 0 <br />0 Fusucnoutacipm. 0 DRIVEN DEPTH OF GROUT SEAL 1PECIRCATION O IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E 0 RIONFTORNO OROUT SEAL PUMPED: 0 Va. 0 No CONCRETE PEDESTAL. BY twsupt Or. OH. s r,' <br />APPROX. THIGH LOCRING CHESTER BOX/STOVE PIPE $g` <br />PROPOSED CONSTRUCTION/DRILUTIO METHOD MUD ROTARY AIR ROTARY AUGER.— CABLE OTHER <br />I NEMERY CERTIFY THAT I HAVE PREPARED THIS APPL/CATION AND THAT THE WORT WILL BE DONE IN ACCORDANCE WHIT SAN JOAQUIN COUNTY OPOINANCES. STATE LAWS, AND RULES AND <br />REOULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR UCEIGHD AGENT'S SIGNATURE CERTIFIES no TOLLONANG: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WONT FOR WHICH <br />THIS MAST IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATON LAw9 OF CHJF-ORMA.- CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLIDIMNO ' I CERTIFY THAT IN THE PERFORMANCE OF THE W011( FOR wilocH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT 70 WORKMAN'S COMPIDISAITON LAWS OF <br />CAUFORNIA.- THE APPUCANT mug/ cALL 24 Noun. IN ADVANCE FOR ALL REGUIREo marmnom• AT peal 645-1421 COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />ear. AL d4&iltal/YILJILy'Ld TEN PEE-171,714. L.' <br />PLOT PLAN !Draw w Boolo! Scale ' to <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OM TROMSO) <br />2. OUTUNE OF THE PROPERTY, 00/010 DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SEEGERS. <br />3_ <br />DIMENSIONED OUTLINE& AND LOCATION OF ALL EXISTING AND PROPOSED E. LOCATION Of WELLS WTTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />CacmEnto.. <br />ACCoUNTINO ONLY <br /> <br />r FACE <br />Ft COMA FEE INFO AMOUNT RBSETTED <br /> <br />(e...19C ASH RECHVED EY ',ATE <br />rEFIATAITIVICI MpLFEAt MUMMER . Imvoicit <br />65-0 <br />C <br />////57f.tr.