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319 ji APPLICATION FOR WELLIPUMP PERMIT F AN JOAOUIN COUHTv PUBLIC HEALTH SERYICES } ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCXTbN, CA 95201.388 (209) 468.3420 11 NOR-REFUNDABLE PERMIT EXPIRES f YEAR FROM iUATE ISSUED (CompWv in Triplicat19) 11' APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWoR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUiN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNN L. C�H}V C�nr_`L•- 'a . PARCEL SIIZFJAPN P y OWNER'S NAME L S AppRESS Lp4 7 I� ,••�+ 02PHUNE♦ �� 1r CONTRACTOR r llT-1 AbORE88l•�� - 6nX33{�. RioVIAAIJCr1;.57-5$I��o�l 110�j7s?�4 _O SUB CONTRACTOR ADDRESS II I! LICE PHONE A TYPE OF W_ELLIPUMP: VINEW WELL ❑ REPLACEMENT WELL , ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR 11 .r © VAPOR EXTRACTION WELL N t ❑ (TYPE OF PUMP) New 13Repstr H.P. DEPTH PUMP SET FT, i FIRST WATER LEVEL O �. © OUT�OF.S RVICE WELL, © GEOPHYSICAL WELL N I 'I ❑ SOIt BORING �}�L* pail O="'w h L " dl-6 .LAe -au �s , ' ft•�y s ...e e 9 DESTRUCTIOW W' _ — V I "^�v'� �q 3�TrMOr1 fY•t D4 4 j INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -y A k ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION t I a DIA.OF CONDUCTOR CASINO I` mVV l) p ❑ OOMEBTIClPRIVATE %GRAVEL PACKISrzE3� TYPE OF CASINOlSTEELIPVC 5r,�4� ,�� DIA.OF WELL CASINO rl p i ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL.2'4 0 3y, Ij_ SPECIFICATION T R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY f• I] '1 GROUT BRAND NAME C( n E ) , A MONITORING GROUT SEAL PIMPED:.1 Yes ❑No :I CONCRETE PEDESTAL BY ORILLFR:❑Yee ❑N A S (p'L p °� APPROX.DEPTH w LOCKING CHESTER SOX/STOVE PPE , S !. PROPOSED CONSTRUCTIONIDRILLIND METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 11 it I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND F� REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH p THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRINfl OR SUS-CONTRACTING SIGNATURE CERTIFIER 1 THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT To WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT UST Cir 24 HOURS IN ADVANCE FOR ALL REOUIREb INSPECTIONS AT 120191169-3413. COMPLETE DRAWING AT LOWER AREA PROVIDED. '_x`11-� :I Sigrod X Tltfe `a li Oste I OT PLAN IbreN to Sealel Same 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL 8Y8TEM OR PROPOSED j 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. �� EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ` G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WFUS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ' F, STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, 11 ON THE PROPERTY OR ADJOINING PROPERTY. :1 ....:.. ... ......,...... „ ..... . ........ .,.i............ ... ... ----r-.- .i... .....:, .,.... .. .... ... ....... I :. ... . 'I. .... ................... . .... .. .. :........................... .. . ..... .. .... ..... ....... : =.... ;'I 1 .... ..... . r. ;....; ... .. . .. I# :... . ._ ApPIlwtion Accepted By - ...:'�,,"'.'-� I� Date- OL/'�" / r Area .•,,..� I} 'I Oroul insPectlon By Date Pump Iropeetivn Sy !} a Date Oestructivn IrrpxGvn By !I I vote Comments: ACCOUNTING ONLY: AIDd FACS II 1 PE CODES FEE INFO AMOUNT RQMITTEO CHECIVICABH RECEIVED BY DATE I� PERIWITIBEAVICE REQUEST NUMBER INVOICE 1 CQD o0 e >