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MrrLItAIIUb FUR WELLIPUMP PERMIT . PAYMENT SAN JOAQUIN COUNTY PUBLIC HEALTH SER'_ jS RECEIVED ..� ENVIRONMENTAL HEALTH DIVISION �.✓ P.O. BOX 388, 304 EAST WEBER AVENUE, STOCI(1'ON, CAg�1_�� Q IS-0b (209) 468.3420 --'SAT�7 •' ��it1 t PUBLIC Hf_A •Tfl jL.,.PvIrC3 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HLALI H CIVI510N (Complete In Triplieatal 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 COMPUANCE WITH SA JOAQUIN COUNTY DEVELOOOPjMME'NT TITLE,CHAPT R 9-1115.3 AND T E STANDARDS OF SAN JOAQUIN COUNTY PUSUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNO J5 CI L ereg '� / �1�, L`�r� CITY �•- PARCEL 3IZE/APN; OWNER'S NAME I7 '1C� ADDRESBSirJ �jd-_S . C r j�,3O ^ C t'�MFRA@1<pR GC1VtljJYl _ �/y�/(� PHONE S '—JSP/ ADDRESS �7� Lf�� PHONE ory�sue coNrRACTOj( kg3�� ,!)• AooREea r /i7�Jt UC�r��PHONE lr '��F TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL+r ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL t ❑ (TYPE OF PUMNew❑Repalt H.P. DEPTH PUMP SET FT. PI y � 1:1 OUT-OF-SERVICE WELL C1 GEOPHYSICAL WELL/ FIRST WATER LEVEL SOIL STRING 1) B DESTRUCTION: 1Ol.Mr mil^• elfin � �I ✓S ',�f �Ia•�a Z'� INTENDED USE TYPE OF WELL CONSTR TION SP ECIFiCAT10N$ _ ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I/L.'� �- A A ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE DI .OF CONDUCTOR CASINO I D TYPE OF CASING/STEEL/PVC G DIA.OF WELL CASINO _�//1.ryZ/r't.".LLtli� ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 3U D 11 SPECIFICATION IRRIGATIONlAG 13 OTHER R U7 GROUT SEAL INSTALLED BY GROUT BRAND NAME a1A4 0W,A& 1I MONITORING E /� [I/ GROUT SEAL PUMPED: ❑Yea No CONCRETE PEDESTAL BY DRILLER:❑Y•a APPROX.DEPT4!5) o'j=tQ O '� �-�" �� 1:1 No S , LOCKING CHESTER BOX/STOVE RPE PROPOSED CONSTRUCTIONAMLUNO METHOD: MRYS A!R ROTARY AUGERCABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANC REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICF ' THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' HE ICAMUST C 24 HOURS IN DVANCE FOR ALL REQUIRED I PECTIONa AT 120$:4", PLET23. COME DRAWING AT LOWER AREA PROVIDED. 8lpned XTitle Dote V-vI Va ' 1 PLOT PLA I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY•) • to 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4• LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PRD POSED 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION F SEWAGE DISPOSAL RALS OFOSYSTEMS. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION OF WELLS WITHIN RADIUS E ONE HUNDRED FIFTY Ff. ON THE PROPERTY OR ADJOINING PROPERTY, .. .... .... .. .. .. .. .. .. .. ............ .. .. .... .. .. -- -- .. .. .. .. .. .. .. .. .. .. .. ..... _�_ .. ._.._ —. ..; i.. ...;.. A DEPARTMENT USE ONLY Appllcatlon Accepted By t--) Dactlon By Date bl 'P Grout Irn Are• Date Pump Impaction By Deatroetlon Irn Data peotlon By 0 Date �� C T ACCOUNTING ONLY: AIDI FACT J sem/ PE CODES FEE INFO LINT REMITTED HEC /CASH RECEIVED BY DATE PERMIT/ UM fEAVICE REQUEST NUMBER INVOICE 3/7 � vo h I