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APPLICATION FOR WELLIPUMP PERMIT ° -�POAN JOAQUIN COUNTY PuaLk WEALTH SERB" ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOUTON, CA 86201.388 (208) 488.3420 NON-REFUNDAll PERMR EXPIpEf 1 YEAR FIIOM DATE If8UE0 APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PEFW TO CONSTRUCT AND/on INSTALL THE WORK DESCRWED.T JOAN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1 1 15.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,hB8 APPLICATION 18 MADE IN COMPLIANCE 1MTH SAN ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APIC_ [ �� T,r 1.A\f c 1�.�� C,.("Cl CITY sICSC OWNER'S NAME ��- PARCEL SIWAPNI 1 C� CONTRACTOR ' ADORE I 4 CLQ{ i IY lA� �t' k6c, PHONES �6 ADDRESS_44� ._l I; LIC# PHONE#—" `s?-czQ. SUBCONTRACTORMm ADORE SSZ ZS MLntf L LICi��Z.Z6R PHONE*Z�}6SjffkL TYPE of Wg LJPUMP ❑ NEW yypi MENUMMENNEwomm ❑ REPLAcEMENT WELL ❑ MONITORING WELL ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ cRo88-CONNECT REPAIR ❑ VAPOR EXTRAcTioN WELL: ❑Now❑11 p r H.P.��_, 1E HP Z DEPTH PUMP SET FT. ✓ (TYPE OF PUMPI �yF1�RBT WATER LEVEL `' 0 ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL�f LAl SOIL BORING�Q'1 t{``Z ❑DESTRUCTION pa tla�IRI TraE r B Yao�i�..T.iwq:.a.-�.cATiDNB A ❑ INDUSTRIAL ❑OPEN BOTTOM dA.OF WELT.EXCAVATION � \ y.e S DIA,OF CONDUCTOR CA81NG I— j ❑ DoMESTIC/PRVATE ❑GRAVEL PACK/6RE AA TYPE OF CASfNGA$'TEE�pVC��_ ,,,��„ dA.OF WELL CASINO Z O ❑ PUBUC/uwrAL %DRIVEN DEPTH OF GROUT SEAL, SPECIFICATION_�� drn�.%C_ R ❑ IMSGATION/Ao ❑OTHER GROUT SEAL INSTALLED By GROUT BRAD NAME ,o MONITORING GROUT SEAL PUMPED: ❑Y. w E ' C St-C 1 _ T��pK;.-G) CONCRETE PEDESTAL BY DRIUFq:❑Y. ON. S APIROX.DEIN T' LOCKWO CHESTER BOX/BTOVE PIPE `N S PROPOS METHOD: MUD ROTARY AIR ROTARY�AUGER�CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED TENS APPLICATION AND THAT THE WORK WIL BE DONE N ACCORDANCE WITH SAN JOAOUN COUNTY ORDINANCES,STATE LAWS.AND RULES AIM' REGULATIONS OF THE SAN JOAOULN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR VIIINCR TWS PERMIT 18 MOM,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORIMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S FIRING OR VJWCONTRACTM SIGNATURE CERTIF" THE FOLLOWING: •1 CERTIFY THAT IN THE OF THE WORK FOR WHICH THIS PERMIT is ISSUED,I SHALL EMPLOY PERBONS SUBJECT TO WOMMA M'S COMFMSATION LAWS OF CALIFORNIA.• E APPLIC NT MUST CALL 24 IN ADVANCE FOR ALL RtGU1RE1 INSPECTIONS AT=0 48114428. COMPLETE DRAWING AT LOWER AREA PROVIDED. «, Tie. Q cmc M c�y��r o.t. Z 4 C`l-5 TTS- 4� PLOT PLAN(Draw to BONN Bodo •to 1. OF STREETS OR ROADS NEAREST TO OR BOUMNDINO THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROP08ED Y.OUTLINE OF THE PROPERTY,GWIIO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. B. DMS OUTLINES AM U)CATIoN OF ALL EXISTING AND PIiOP0M S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. 81781CTURES,INCLUDING COVERkD ARM SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. .......,..............,................................ .:...... - ...;... .. .. ..............:......................:......:......................:......;.......:...... .... ,! .. .. .. WX .VM :......:......;.......:.......:.............;............I.............; .. .. .. ..:.. <... . :..............:.... .. :.. :....................:..............:..... .. .. .. :.. ...;.. ..:.. .. .. .. .. .. .............. . :......<....................:......:..................... .. .. .. .............:.............:.... .. .. .. .. .. .. .. :.... .. :.... ......:...............:......:......:.....................:... .. .. .. . .. r u ;,T -yw ARTMENT USE ONLY Appftadon AompoW 8. (.1 DN. 3 7 �� Arm Grout Mrp.adon By Dote Pump kap-lon By Deft Drtruotlon In murtion BY Be* Commanb: { ACCOUNTING ONLY: AIO/ FAC# �/ PE CODEB FH INFO AMOUIIT CHW"/CASH RECOVED BY DATE P6NIT/9EMVICE RSasIRtT NMMBEI IfVDICE 6