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T. WII.. UI W CONf7RVCT10N 1FECIHCARON■ <br />fi� INDUSTRIAL Q -•I OPEN BOTTOM DIA Of WELL EXCAVATION OIA. OF CONDUCTOR CASING <br />rO"'COMFUMIMV-rE 1J GRAVEL PACKISI2ETYPE OF CASBNIlSTEELPVC OLA. OF WELL CASING <br />❑ PUSLICOMUNIGIP.AL ❑DRIVEN DEPTH OF GROUTSEAL SPECIFICATION <br />D IRRIGATION/AG n OTHER OPOVT SEAL INSTAIIEO BY GROUT BRAVO NAME <br />13 LIONITOINNO GROUT SEAL PUMPED: QY- ❑No CONCPETE PEDESTAL BY DRILLER: Q Y.. ON. S <br />APPAOX- DEP7H LOCKRq CHESTER SOKOBTOVE PIPF r <br />FROFOSED CONSTRUCTIONIDFBLUNO METHOD: MUD ROTARY AIR RTTARY AUGER CABLE OTHER <br />APPLICATION FOR WELLIPUMP PERMIT daell ;7 <br />SIGNATURE CERtIFIES THE FOLLOYMNO: 'I CERTIFY THAT W THE PERFOFIIAANCE OF THE WOES( FOR WH <br />kf THIS PEMPT IS ISSUED, 1 RHALL NOT EMPLOY PERSONS GU"CT TO WORKMAN'S COMPENEATTON LAWS OF CAJJFOpNM.• CONTIIACTOa'e MPING OR gUR.CONTRAC7Rq SIGNATURE <br />THE • '. C T R4Q SIG <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />%UO IN ADV CE FOR ALL 1EOLSRED IN/tFECTIpyNf�A�T, IZOSI Ai411 <br />ENVIRONMENTAL HEALTH DIVISION <br />elf_d Y_ Till, <br />rac <br />P♦O. BOX -M a> 304 EAST WEBER AVENUE:, STOCKrON, CA 9S20i 8 <br />7 <br />5 PLOT PIAN ID.— to BC.I.I eq.:. • tv <br />i, 1. NAMES OF STREETS OR ROAD$ NEAREST TO OR NDINO THE PROPERTY. <br />1209) 468.3420 <br />2. OUTLINE OF THE PHOT , V, OIVINa DA./FNSIONS AND NORTH DIRECTION. <br />(LON•AFFUNDiltlF PEBM7F EkflRE4 1 TFAR FROM DATE ISSUED <br />ICfnpWf le Trip utfl <br />AP--ATION 18 PL°RL BY MADE TO THE SAN .IOAt my COUNTY O'OA A A'ERMOT TO CONMIUCT ANV/ A IN6T.A L THE WOOW DESCRIBED, THIS APILN:.A7N)N <br />JOAQUIN <br />COUNTY DEVELOPMENT TrFLE CHAPTER <br />!S AiADF IN CDMPUANCE MYH S.eN <br />9.1116.3 AND THE STANDAPDS OF SAN JOAOUSI COUNNTT)"LIC HEALTH SERVICES. ENVIRONMENTAL HE•LTH DIN BION. <br />JOE'ADORESSAR APNF <br />CRY <br />ON TTFE PROFEITrY'OR AOJOWlNO PPOiEFTY. <br />PAh,EI BfjFjAF1L <br />OWNER'S NAWON <br />�I <br />Z' 4y �ESfl /•Tp f/F <br />NONE <br />CONTRACTORP�• <br />.....i......l.. .: , :.....'.....n... i <br />SUs CONTRACTOR <br />. . .... s.. .. <.....:.... ... .......... ..... <br />- .... ..;.. • .... ... i .. .. <br />i ... 1. ... <br />.. . <br />... f . <br />ADDAFSA LIC <br />PHONE 41TYPE <br />OF MP ❑ NEW WELL <br />F-� <br />Q REPLACEMENT WELL ❑ MDIIITORINa WELL . ❑ OTHER _ <br />EkWSTALLATrJN <br />❑ WELL SYSTEM REPAIR C] CROSS -CONNECT REPAIR Q VAPOR EICTRA.CTNON WELL <br />Q N., 13 p".11 <br />rTwE <br />F r„J� <br />H.P. DEPTH PUMP BET___FT. FIRST WATER LEVEL <br />❑ OUT -0F -SERVICE WELL Q GEOPHYSICAL WELL f Q SOIL BOR114U <br />❑ DESTRUCTH)N: <br />A" <br />T. WII.. UI W CONf7RVCT10N 1FECIHCARON■ <br />fi� INDUSTRIAL Q -•I OPEN BOTTOM DIA Of WELL EXCAVATION OIA. OF CONDUCTOR CASING <br />rO"'COMFUMIMV-rE 1J GRAVEL PACKISI2ETYPE OF CASBNIlSTEELPVC OLA. OF WELL CASING <br />❑ PUSLICOMUNIGIP.AL ❑DRIVEN DEPTH OF GROUTSEAL SPECIFICATION <br />D IRRIGATION/AG n OTHER OPOVT SEAL INSTAIIEO BY GROUT BRAVO NAME <br />13 LIONITOINNO GROUT SEAL PUMPED: QY- ❑No CONCPETE PEDESTAL BY DRILLER: Q Y.. ON. S <br />APPAOX- DEP7H LOCKRq CHESTER SOKOBTOVE PIPF r <br />FROFOSED CONSTRUCTIONIDFBLUNO METHOD: MUD ROTARY AIR RTTARY AUGER CABLE OTHER <br />r 1 HERESY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT TME WOPK WILL BE DONE M ACCORDANCE 1WRTH SAN JOAOUIN COUNTY ORDINANCES. SATE LAWS, ANO RULES <br />j REGULATIONS OF THE SAN JOAOUN COUNTY, HOME OWNER OR LICENSED AGENT'S <br />SIGNATURE CERtIFIES THE FOLLOYMNO: 'I CERTIFY THAT W THE PERFOFIIAANCE OF THE WOES( FOR WH <br />kf THIS PEMPT IS ISSUED, 1 RHALL NOT EMPLOY PERSONS GU"CT TO WORKMAN'S COMPENEATTON LAWS OF CAJJFOpNM.• CONTIIACTOa'e MPING OR gUR.CONTRAC7Rq SIGNATURE <br />THE • '. C T R4Q SIG <br />FCI}.OWINO: CE <br />1 CERTIFY THAT IN THE RMAHCE OF THE WOW FOR WTSCH THIS pERA1TT IS IRSUED, 1 SHALL <br />ATUREATION E <br />O}-I�EF NB SUBJECT TO 8-COWAH'S <br />CALIFORNIA,' i! APFWS <br />T MUST CAL ORS <br />%UO IN ADV CE FOR ALL 1EOLSRED IN/tFECTIpyNf�A�T, IZOSI Ai411 <br />223. COMPLETE DRALWNO AT LOWER AREA PnoVADFD. <br />elf_d Y_ Till, <br />rac <br />'^J <br />' <br />7 <br />5 PLOT PIAN ID.— to BC.I.I eq.:. • tv <br />i, 1. NAMES OF STREETS OR ROAD$ NEAREST TO OR NDINO THE PROPERTY. <br />IECCk 1CAFH <br />2. OUTLINE OF THE PHOT , V, OIVINa DA./FNSIONS AND NORTH DIRECTION. <br />.. LOCATION OF HOUSE BEWAOE DISPOSAL SYSTEM ort TIAOPOSEO <br />NE <br />O. DIMENSIOD OUTUNFS AND LOCATION OF ALL "ISTM AND PROPOSED <br />FXPANIION OF SEWAGE DISpOSAL RY67EM S. <br />BRitXTURES, SOCLUOYWO COVERED AREAS SUCH AS PATHOS. OfSVEWAY6, .,No <br />B. LOCATION OF WELLS WITHIN R101U6 OF ONE HUNDFIFD FIFTY FT <br />1MALXS. <br />ON TTFE PROFEITrY'OR AOJOWlNO PPOiEFTY. <br />V 3r (1 <br />.'. ,. � .. 1. ..i.. ...F.. °. .i.. ...... ... <br />. ...... .e. ....� .: . ... .....• ........ :.. <br />e <br />.....i......l.. .: , :.....'.....n... i <br />....... <br />. ,.......... <br />. . .... s.. .. <.....:.... ... .......... ..... <br />- .... ..;.. • .... ... i .. .. <br />i ... 1. ... <br />.. . <br />... f . <br />..n.......... .........:. <br />...... <br />. . .... .... <br />ve <br />:.....:.....:..:.. : <br />SAN J <br />DEPARTMENT USE ONLY ......�..�� P <br />APPllcsppn T.cc,T.led BY \- 1` / �+ •'�A�,Y1��'� �/jj �� p.I ��1 / Nfv_� l z•- <br />n— I—p—lo BY <br />D-Uwti- 1,.P-.]- BY. <br />ACCOUNTING ONLY: A1UF <br />EACf <br />FE COOFA <br />FE! INFO AAI,OUNT RETAITTEU <br />IECCk 1CAFH <br />FECVI1VED BY <br />OATS <br />PflUAUSS�EFMCE KODUE'FT NLNAER <br />INVOICE <br />fe1 <br />V 3r (1 <br />�40Q G� <br />c <br />`. <br />