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6 <br />4.t.• • <br />• <br />Appicodlon AvEINENO SY <br />Grout IropootIo^ ST <br />Do4truetton Inspection BY <br />Commonly <br /> Dom 4- I L• <br />-7 -1 - <br />Dets <br />DAM PE.mp Inspect on BY <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH OIVISION <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br />IN% 468-3420 <br />icr4ock <br />(t4 <br />:Km ADDRESS/OR APNS )0554Y7 4cp.).-1 d SIlTY -777c.y PARCEL SIZE/APN/ <br />OWNER'„.Thr\\ rnaLICorx ADDRESS PF1ONE r.Zc,3S_aLj5-414- <br />CONTRACTOR t rZ.5 /4(_z ADDRESS ( Mr) kuc# 453916=2ITONE saszv V <br />GUI CONTRACTOR ADDRESS <br /> <br />LiCr PHONES <br /> <br />TYPE Of WELL/PUMP: 0 NEW WELL REPLACEMENT WELL <br />iirZSTAILAT)ON 0 WELL TeSTEM REPAIR <br /> • oerr Orait .0 Repair H.P.— I tit- <br />MONITORING WEI I s• <br />ID CROSS-CONNECT REPAIFI <br />DEPTH PUMP SET1C2F1. <br /> <br />D OTHER <br />VAPOR EXTRACTION <br />FIRST WATER LEVEL <br /> <br />NOteRECURBABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(CARIOCA In Triplicate) <br />APPLICATION 16 HEW BY MADE TO THE SAN JOAQUIN COUNTY FOP A PERMIT TO CONSTRUCT AND/OR INSTALL THE WC411L DESCRIBED. THIS APPtIcATION IS MADE IN COMPLIANCE WITH BAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS Of SAN °MILAN COUNTY PUBLJC HEALTH SERVICES, EtiVIRONMENT AL HEALTH DIVISION. ) .1 <br />fTYPE OF PUMP/ <br />our-or-scrivicr Arca 0 GEOPHYSICAL WELL S eon_ (WRING 8 <br />DEsTRUCTION: <br />TYPE OF W51.1. <br />El OPEN BOTTOM DIA. OF WELL EXCAVATION <br />0 CRAvEL PACIOSIZE TYPE OF CASING/STEEL/PVC <br />DRIVEN DEPTH OF SPOUT SEAL <br />0 OTHER GROUT SEAL INSTAiLED BY <br />GROUT SEAL PEIMPED 0 Ym. ONT. CONCRETE PEDESTAL BY DIEILIFR: Dv.. ON. <br />LOCKING CHESTER BOX/BTOVE EWE 5 <br />PROPOSED CONSTRUCTION/MUM] METHOD. MUD ROTARY AIR ROTARY AUGER C MILE OTHER <br />CONSTRuC11014 SPECIFECATIONS A MTV_ Jjap_LISE o INDUSTRIA! <br />-'MESTICITcNVATE <br />D PUBLIC/MUNICIPAL <br />IRESCATION/AG <br />MONITORING <br />APPROX. DEPTH <br />DIA. OF CONDUCTOR CASINO <br />DTA. 3F WELL CASING <br />sPECIFICAT ION <br />aROIA BRAND NAME <br />I HERESY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE ovoRK. WILL BE DoNE IN ACCoRDANCE WITH SAN JOAQUIN COUNTY ORDRANCES, STATE LAWS, ANC RULES AND <br />REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OP LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORE FOR WHICH IT <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TD WORKMAN'S COMPENSATION LAWS OF CAUFORNIA-' CONTRACTOR'S HIRJNG OR EILIS-CONTRACTING SIGNATURE CERTIFIER <br />r--. THE roliovoNo, - 1 CLETTIFY THAT IN THE PERFORMANCE Of THE NOM( FOR WHICH THIS TIMM IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF ......, <br />CALIFORNIA.THE APPLICANT (Auer CALL 54 HOURS IN ADVANCE P515 ALL Raouintn irraoscrioNA Al' (2001 44P-3421. COMPLETE DRAWING AT LOWER AREA PROVIDE°. <br />Signed X —*.of\A:Al&L) Title //4121_,40 • Ow* 4 1 .10 oC--- _ <br />PLOT PLAN (Drew to ScotEel Soak - <br />2. OUTLINE Of THE PROPERTY, °WINO DIMENSIONS AND NORTH DiftCTIDN. <br />' — <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERrr 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. .7.3 <br />sr RUC TURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS. AND WALKS. ON THE PROPERTY GA ADJOINING PROPERTY. <br />DEPARTMENT USE ONLY <br />Accourcnoo ONLY: [—AIDS FACO <br />. PE CODES FEE INFO AMOUNT REMITTED CNECIEJ/C ASH RECEIVE° BY DATE PERMIT/SERVICE REQUEST NURASER INVOICE <br />7- ---) c <br />0 77.: i1III '1-0 -