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APPLICATION FOR WELLIPUMP PfRMtT ! y SAN JOAOUIN COUNTY PUBLIC HEALTH SIR"fjw-) k ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKMN. CA 98201-W {2991469.3420 M011•REFUNDAKE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CamPMts In TrlolkllTe} :� APPLICATION 19 HERE BY MADE TO THE SAN JDACUIFI COUNTY FOR A PERMIT TO CONSTRUCT AND/ORR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNrY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOBAbbRE33lORAPNS 1305 Escalon Avenue Escalon Ctre PARCEL SIZETAPNS bWNER•9 NAME City of Escalon �RESSP. 0. Bax - PHONEN38-4100 - coNTRACTOR V. & W Dri i linq .,_ AVDREsd 5 ESP-EierSgn Ct, ti.omirsta 720904QHE.707_374-Z81 t RUB CONTRACTOR ADDRESS ;I. LICS PHONE S E TYPE OF WELIJPUMj ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL• !F ❑ OTHER AnrpbaI I- ❑ INSTALLATION ❑ WELt SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL S ,! ❑New❑p".1, H.P.. DEPTH PUMP SET FT. I1 FIST WATER LEVEL O (TYPE OF PUMP1 .i - Cl OUT-OF-SERVICE WELL ❑ OEOPHYMCAL WELL S ❑ SOIL BOMNGE��tal S ❑DESTRUCTION. grout via pressure methc)ds INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p ❑ DOME9TICIPIVATE ❑GRAVEL PACxlSIZE TYPE OF CASING/STEEL/PVC f CIA,OF WELL CASINO p �^ ❑ PUSLICIMUNICtPAt ❑DRIVEN DEPTH OF GROVT SEAL "I SPECIFICATION x ❑ IWUGATION/AO 91 OTHER GROUT SEAL INSTALLED BY f OROUT BRAND NAME E MONIOWNfl GROUT SEAL PUMPED: ❑Ver ❑Ne it CONCRETE PEDESTAL BY DRILLER;❑Y. ON. S k APPROX.DEPTH LOCKING CHESTER SOXISTOVE PIPE S f PROPOSED CONSTRUCTtON1dILLIND METHOD: MUD ROTARY AIR ROTARY AUGER '� X CARLE OTHER H . I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPmATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND + REGULATIONS Of:THE SAN JOAQUIN COVNTY. HOME OWNER OR LICENSED,AGE11IT'8 SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 1 THIS PERMrT IS ISSUED,I SI(ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTMO SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT 1N THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMrT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'e COMPENSATION LAWS OF CALIFORNIA.' THE1�CANT VSfI�r CALL 24 HOURS IN ADVANCE FOR ALL REOUREO PINS. TIO/NS AT 1 4SwJ422. COMPLETE DRAWING AT LOWER AREA PROVrOW. f ' /��'L, 1 PLOT PLAN!Drew to Saelal Saele 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. . 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR T'ROPOSED i 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 11 S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, STRUCTURES,INCLUDINO COVERED AREAS SUCH AS PATIOS DRIVEWAYS.AMC WALKS ES, ON THE PROPERTY OR ADJOINING PROPERTY. See "Attached Map F ... F - - DEPARTMENT VSE ONLY EL APpllaetbn Aaeepted BY_till l/L.l t\�l+ f/�. Greet IMee pllon By I 3`�OA,- 11 l(AAA Of— One�' I Z" P., ingearlen BY Dele Oeetrnollon I—Pxtlen Sy Ona Cem -tr: Ei I ACCOUPITINQ ONLY: AIDS FACS l PE CODES FEE two AMOUNT REMITTED CFIECKNICAR14 RECEIVED BY DATE �I PERNIITISERVICE REQUEST N11MINGR WVOrCE sai t.oc) tot 3(0- Q 13 -S i 1k 'r - Pub.Health Serv.-Enviro.173(3/96)