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APPLICATION FOR WELLlPi1MP PERMIT <br /> SAN JOAOUIN COUNRT PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.Q. BOX 388, 304. EAST WEBER AVENUE, STOCMN, CA 95201-368 <br /> (2091 466.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (C®mPlatot in Trbiliestel <br /> 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 COMPLIANCE 6VITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111 5.3 AND THE 67ANOARD6 OF Sp!t JOAOVIN COUNTY PUBLIC HEAL Tli SERVICES,ENVIRONniENTAL HEALTH DIVISION, <br /> JOS ADDRESS/OR NRPNrY � �p,�.l. <br /> CITY_ U C `� PARCEL SIZEIAPNR <br /> ONRlER'S NAME -~ _ tl <br /> '�..�.• •s,,- 4_D.AODRDE5R8E <br /> PHONE <br /> CONTRACTOR LIc4j .1 <br /> PHONE or/ aG' <br /> SUB CONTRACTORADDRESS <br /> LICI_ PHONE 8 <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMFIfT WELL ❑ MONITORING WELL S ❑ OTHER -- -- <br /> .�, INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR <br /> ❑ VAPOR EXTRACTION WELL/ O <br /> ❑New�Ropwlr H.P. DEPTH PUMP SET FT. <br /> (TYPE OF PUMP) FIRST WATER LEVEL _ <br /> ❑ OUT-OF SERVICE WELL ❑ GEOPHYSICAL WELL x ❑ SOIL BORING ^ <br /> H <br /> 11DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - - <br /> ❑ INDUSTRIAL 11 OPEN BOTTOMA <br /> DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> 11 DOMESTICTRIVATE 11 GRAVEL PACK/SIZE TYPE OF CASING/STEFLJPVC DIA.OF WELL CASINO D <br /> D I <br /> ❑ I'VBLIC/Ml1N!CIPAL 13 DRIVEN DEPTH OF GROUT SEAL _ SPECIFICATION R <br /> ❑ IRRMATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL.PUMPED: ❑Ver ❑No CONCRETE PEDESTAL BY DRILLER:❑Yrr ❑No S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 5 �1 <br /> PROPOSED CONS TRUC TIO WDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEgEBY CERTIFY THAT 1 HAVE PREPARED THIS APF{.ICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,ANOFlULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR C <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIF <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP4NSATION <br /> CALIFORNIA.- THE M4*CAN MUST CA 24 HOURS IN ADVANCE FOR ALL REOLRREO INA TION!AT 01 46034X3- COMPLETE DRAWING AT LOWER AREA PROVIDED. LAWS OF <br /> t . / <br /> Slgru,d XK }v'G+L 4C.G� Tltlw id✓�� <br /> PLOT PLAN 10—to Serlwl Serle 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> F 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> AJ <br /> i. <br /> (77 <br /> lake <br /> _NV R ,i' WEN <br />