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--+ APPLICATION FOR WELL/PUMP PER Im Sa. JOAQUIN COUNTY PUBLIC HEALTH S, ACES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKT® , CA 95202 (209) -3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete is Tripllcatal APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SHIN JOAQUIN COUNTY DEVELONF �(1AFTER 111 .L3ANND THE STANDARDS/OF SANR,IOAQUIN,FOU PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Joe ADDRESS/OR APN# /IyIW�I� Ili I nF.&�1-r"In ICrI l f(j� CITY /11/ �e �—e ® !J / —�2LC�.,,q�p U"C'ly� /�/�P�ARCEL/SSIZE,APN.S8 3 539-&4 3 OWNER'S NAME / G�.1 1'�(c`� l` h ADDRESS 3 ��f1�?rL--«"^'""Q7'� �r� a-t ' FHONE 1 CONTRACTOR �e 1 V 1 A ADDRESS ,�L" __ els 1 ; PHQNE A_Z43! SC62 SUB CONTRACTOR ADDRESS - ` - CAPHONE g TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ® (TYPE OF PUMP) w 11VEL New Repair H.P. DEPTH PUMP SET FT. FIRST WATER LE ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING l� B F1 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS // .A A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONIt�y'p�/j�I DIA.OF CONDUCTOR CASINO IV /J 11PH DOMESTIC/ IVATE 11 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC 1/L DIA.OF WELL CASING ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ — SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY p`A.( OITT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED:y Yea ❑No NCRETE PEDESTAL BY DRILLER:®Yea ®No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I/HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001400-3423. COM E DRAWING AT LOWER AREA PROVID D. �p �/ A l ® Z SI®noel X , `'� ` Tltla V -kz �I t oT PLAN(D,. to Sole)Scale -to 1. NAMES OF STREETS OR ROA AREST TO OR BOLI DING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSION NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. i J. .. . ..... .. .. ..... . .. ....................... . .. .....: ... . I I DEPARTMENT USE ONLY '/ Application Ac—pled By —Data—/ Gy! �iArea . R-i Orout Impaction By Date Pump Impaction BY Date Dealn.tlon lnepectlon ey Date Cenornenta• ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO LINT REMITTED -,CASH RECEIVED BY DDATgE.�/ PERMITISS€RMCEARjEQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(1/97)