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APPPLiCA T IGiY FOR WELLIPUMP PERMIT AN JOAGUIN COUNTY PUBLIC HEALTH SERYL ENVIRONMENTAL HEALTH DIVISION D ,tib P.O. BOX 388, 304 EAST WEBER AVEN1JE, STOCKTON, CA%Ml- 88 (2091 489.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplats In Tripriaatu) APPLICATION IS HERE BY MADE TO THE SAM JOADUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPUCATEON IS MADE IN COMPLIANCE WITH SAP, JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH OMSION. JOB ADDAESBJOR APNf ! 0 3 61 5I I'Q i�, _CITY ✓�r.�. PARCEL 31ZEIAANIZ73-1-Sc)-Z3 OWNER'S NAME �V+�'a� r,o dV7L�S �y �O�.N. ADDRESSed.d.&Y PHONE;.9O 8e/2—p CONTRACTOR l7 ��- -RV -��ftG. .. _..,.,.., . .__. AODREesIre- 1��t� �.�.—�u7rCf�710�93 PmoNr ?l v 13 1• 'SUB=gkrlF CTOR G W�.+7 m C. ADDRESS y �J PLIC PHONE 0 � Zr TYPE OF WELLJPVMFI ❑ NEw WELL, ❑ AE]P ACEMENT WELL D MONITORING WELL f ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL f t ❑New©P.P tf H.P. - DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PVA% ❑ OUT-OF-SERVICE WELL - ❑ GEOPHYSICAL WELL f © BOIL BORING 8 r 1 • DESTRUCTION: .wt�C CJCf �I 1%476 CA-'1(Y[ GI.✓'t Z INTENDED USE TYPE OF WELL CONSTRUCTION SPN iRcAT10NS N A t � ❑ INDUSTRIAL p❑OPEN BOTTOM DIA.OF WELL EXCAVATION Q C D _____ OIA.OF CONDUCTOR CASING G ❑ DOMESTIC/PRIVATE pa GRAVEL PACXISIZE TYPE OF CASINOISTEEEJPVCt/ OIA.OF WELL CASING 7 Y G ❑ PUBUCJMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ,3/ -. _ ___ _ SPECIFICATION A ❑ IRRIGATiONIAG ❑. SE OTHER GROUT AL INSTALLED BY GROUT BRAND NAME NIE MOTORING GUS'+ l _ Irr�� GROUT SEAL PUMPED-. ❑Yew ❑No CONCRETE PEDESTAL SY DRILLER:❑Yw ❑Ne S APPROX.DEPTH 4va(S — �fJ..! LOCKING CHESTER Box/nOVE PIPE s PROPOSED CONSTRUCTIOMMMLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE-MBY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL,BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,ANO RULES AN REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'t CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIC THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTIHG SKINATURE CEFITIFIE THE FOLLOWING: 'I CERTIFY THAT 1N THE DEPPOPAAANCE OF THE WORK FOR WHICH THt8 PERMIT 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMA S COMPENSATION LAWS C CALIFORNIA, APPLICANT MUS CA 724 HOURS IN ADVANCE FOR ALL iE3(ARED INSrP*CTIONa AT 12001"84"22. COMPLETE DRAWING AT LOWER AREA PM. EO. Slaved X ,_ Title PLOT PLAN 10—16 Seale)Sede��'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE 0113POSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING ANO PROPOSED - 6. 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 DEPARTMENT USE ONLY ¢Q p IV-L�!'•t,'�'r L I Date G C Are* e . . APPllaatlan Accepted By, - Gfctn Impecllon By Date # Pump smaeceen sr - Dote c Desimmden Impectian By I ,yf� Date .. CPmmetlr: "w' K.C..SCi E ••--• _ -• ACCOUNTING ONLY: AM& FACE PE CODES FEE INFO AMOUNT REMITTED Z C !CASH RECEIVED BY DATE P6iM14TJSERVICE REQUEST NUMBER INVOICE