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APPLiCATIUR FOR WEELIPUMP pERMIT SAR ,IOAs]IN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOY 388, 304 USS`WEISER AVENUr=t STOCMN, CA 9SM-W I (21191469-3420 FRON-REFUNDABLE PERMIT EXPIRES i YEAR FROM RATE ISSUED (Camplatc In Trbllit ai®I APPUCATION IS HERE BY MADE TO THE SAN JOAOWN COUNTY FOR A PERMIT TO CONSTRUCT AND10R INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WrTIR SAN ^ JOAQUIN COUNTY DEVELOPMENT TITLE,CHAFFER D-1115.3 ND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC;FAUN SERVICES,ENVIRONMEHFAL HEALTH DIVISION. y JOB ADDRESWOR'YIPNN fiT{ $ j Jy, PARCEL SITEfAPNd 1 OWNER'$NAME f_ ADLtFiE SS ��y q }J `c� PHONE A CONTRACTOR `3a i "�.. ADDRESS UC (,i, Y PHONE#ly SUB CONTRACTOR_ £ '' _y ADORESS UCO PHONE R { TYPE OF WELL/PUMP; ❑ NEW WELL ❑ RFPLACEMErit WELL ❑ MONITORING WELL N ❑ OTHER INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRO9S-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL A A ! -_� ❑Now D ReI.. H.P, DEPTH PUMP SET FT, FIRST WATER LEVEL d (TYPE OF PUMPI _ ❑ OUT-OF-SERVICE WELL ❑ OEUPHYSICAL WELL# ❑ SOIL BORING B ❑DESTRUCTION: INTENOEO 116E TYPE OF WELL CON&TRUCTION SPECIFICATIONS A , ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO p ❑ DOMESTir"IVATE ❑GRAVEL PACK1817E TYPE OF CASINGISTEEL/PVC DIA.OF WELL CASINO p ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION !F FijIRRIGATION/AGOTHER GROUT SEAL INSTALLED BY GROUT BRAND NAMEMONITORING GROUT SEAL PUMPED: [IYap 13Ne CONCRETEPFDFSTALRYDRILLER:❑Y® ❑No APPROX.DEPTH LOCKING CHESTER 15OXIRTOVF PIPE_ $ PROPOSEO CONBTPUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HERESY CERTIFY THAT I HAVE PREPARED T1418 APPLICATION AND THAT THF WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULE$A ND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING-'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMAENSAriON LAWS OF CALIFORNIA.- CONTRACTOR-8 HIRING OR SUB-CONTRACTING SIGNATURE CERTI 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 COMPTFIRATION LAWS OF F CALIFORNIA.' THE cAN •T CA a 4 HOIARtF IN ADVANCE FOR ALL RE4IARED IN ECTlONB AT �►4aes42B. COMPLETE DRAWING A7 LOWER ARTA PROVIDED. 8117md X Title ATO „K Dsta `� '- d PLOT PLAN IDrt,vv.to Seetal Sesla 'to I 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,OIVIHG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. �. DIMENSIONED OUTHNF,B AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURF8,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, .., F1 Al .... . ......�--; 10 1 . .. ....... - tr Fj AA k I R! JG IR ENO AL