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1 APPLICATION FOR WELLIPUMP PERMI- SAN JOAQUIN COUNTY PUBLIC HEALTH SEtq„rCES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988,904 EAST WEBER AVENUE, STOCKMN, CA 95201368 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in TflpIkEtE) APPLICATION I6 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 91-1115.3 AND THE STANDARDS OF SAN JOAQUIN COU,NJ1TTY'PUU�BLIIC�HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNF �-+I V 1 G- ! II I ��l�� .Iy CITY � Y • 'T`7 �/R �`n �1y PANCEL SIZE/APN/ OWNER'S NAME OY.J` t0� `4`k s ((-''-�A IS`^�'\ ADDRESS vI �6 /( "� , '�T-1 PHONE# ry Req r �J (LJ JC/..lrl-+. AADIORESS I2ZUCDMmc�-I[�Dk-UCIR 'rIf" Q� PWNE�I/OL 13 (4y'�7'S fff�� ( a31oS ADO 4k . 1 ..�.D [SWDSCJ(2-Z&O PHONIYS- E I{fL-- >�J Ift CONTRACTOR J G� j I LIJTIW ❑ REPLACEMENT WELL MONITORING WELL• ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLR TYPE OF WE fFUMP: ❑ NEW WELL ❑N.❑Rro.lr H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL 0 RYPE OF PUMP) ❑ OVT-0E-SERVICE WELL ❑ OEOPHV6ICAL WELL R SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (( A CONSTRUCTIONCONSTRUCTION I 11INDUSTRIAL 11OPEN BOTTOM DIA.OF WELL EXCAVATION `+ DIA.OF CONDUCTOR CASINO 0 ❑ DOMESTICUPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEM)'PVC y C— DIA.OF WELL CASINO 2 _t t O �r ❑ PIBLICRAVNICIPAL ❑DRIVEN DEPTH OF GROVE SEAL J ( SPECIFICATION R ' w10 q�IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY, GROUT BRAND NAME E Fp MONITORING1 GROUT SEAL BUMPED: Vr ❑No CONCRETE PEDESTAL BY OWLLEM❑Vw [IN. 5 ''JJ APPROX.DEPTH 2-o OCKING CHESTER BO OVE PPf 5 PROPOSED CONSTPUCTION/DPoWNG METHOD: MUD ROTARY AIR no AUGER CABLE OTHER I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN MAGIAN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CEPTINES THE MUD1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIAA.' E A CANT MUST CALL M HOURS IN ADVANCE FOR ALL REOMM IN�pE1-��)TIONNS.AT 1 1 MYJyI22.. CO M PLE TE DRAWING AT LOWER AREA PROOjVID D. ,r_— 6lpn.e X TRI. F - \ 1 Y"V Y Dete Ci `t �v 4 t PIAT PUN IO ea.l to el SUN 'te� 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPEPE RTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PPAPoSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND 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. l PAYMENT r W ( sc RECEIVED eAloan DEC 1.3 1q"5 SAN JO, 1 �1 i N C,.,,oNTY D Ip�US �rcy� O PU8LICHkP ;Prl: ibl3Vlis�— P v v EN.VIRQNMANrAiaHrkrHW151PN IlSc:. 11�" / O h 54SG IIF'` iI �� ' � �� DEPARTMENT UBE ONLY ApPimtlan AoaWt. BY Vl�\ L/lilq TC/VT r Det. a Aral Oraut Impmtlen 6, D.t. Pump In.P.etlon BY MI. Dmtruetion IroP.6.a By Diu Lers r mmentE: IACCOUNTING ONLY: MDI PACO i ! PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED DBBY� DATE PERMITISERVICE REQUEST NUMBER INVOICE