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APPLICATIOU FOR WELLIPUMP PERMIT ,,_�AIJ JOAaum COUNTY PUBLIC HEALTH SER% ENVIRONMENTAL HEALTH DIVISIOR P.O. BOX 388. 31 3 EAST WEBER AVENUE, STOCKMN. CA 9MI- 8 (109) 4SM20 BOB-REFUNDABLE PERMIT 1 . APPLICATION IG"M BY MADE TO THE DAN JOAOUMI COUNTY FOR A PERIATT TO CONSTRICT ANDOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOIAN COUNTY DEVELopwENT TRLE.CHAPTER 0-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADDREDDIORAPRR,S oc qv: ba^'v; -20 :. "3k. —CITY �e.co- PA�RCELTOMAPN, OWNER'ONAACE - � irvtiese0' d-Ido CONTRACTOR eCcanQ1C�I 1K1L ADDREOB9g'NeQ\� '{1C.O,t(-Ak( Loc, PHONE,�IIo-369f19�1 SUDCONTRACTOR� e=A T-./M �x \oro.��or,S . enc ADDREoo 7-3t.S LJ.� leJaM Qr G�ico 465 8�'Z Q R �� LIC, 512-2toQj R'{IONE,�2.['�q- TYPE OF WELLIPUMP: ❑ N21N WELL ❑ REPLACEMENT WELL ❑ Momromm WELL I ® OTHER Iy u n�Km-t COue� •1e.r So�mQ\*,r\ ❑ COTALLJLTION ❑ WELL OYBTEM REPAIR ❑ CRDBOCowncr REPAM ❑ VAPOR EXTRACTION WELL, I ❑Now❑RhaC► H.P. DEPTH PLpIRa'CET FT. FO W WATER LEVEL O TYPE OF1LOM 9-;nah m ❑ oVT4F-CERIRCE WELL ❑ GEOPHYISCAL WELL, Ed COO.DOR.'NO 1 5) w �h �yaroP�r1C.1 e 10B/DED USE mu tV lk CONS TION SPECIFICATIONS N A ❑ OIDUOTWAL ❑OPEN COTToM DM.OF WELL EXCAVATION DIA.OF CONDUCTOR CACONO D ❑ DDMEBTICARDVATE ❑GRUIVEL PAouam TYPE OF CACINGISTEELIPHC DIA.OF WELL CACDAO D ❑ PUmxAAJN:CIPAL ❑DCJVEN DEPTH OF GROUT CEAL SPECIFICATION i A ❑ vmoAT1owAo ❑OTHER GROUT BEAL INSTALLED BY GROUT CRAM NAME E ❑ MONTomm GnDuT REAL mwED: ❑Y. 13 N- CONCRETE PEDEBTAL OY DRILLER:❑Yw ❑N. s L1 I APPROX.DEPTH L-I LOCKMIO CHEERER DOXWOVE POPE s PROPOSM COMATRUCflOXl=LLC=ACTFROD: MUD ROTARY AIR ROTARY AUGER_ ( CABLE OTHER a�� hak A.�•ant�o +tient:�o conb�s� of �ee.,e.,F�6en�on��C 4.tb�� 4,r•o— �o�4L, o� eore,►,al�. -\o S.,)&0 1 HEREBY CERTIFY THAT 1 HAVE PMPAAED TM APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH DAN JOACIAN COUNTY ORDNANCE .STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAOU01 COUNTY. HOME OWNER OR LICENSED AGENT'S CIIGATURE COMFIES THE FOLLOWDO:M CERTIFY THAT IN THE PERFORAAANCE OF THE WORK FOR WHICH THOS PErMT 10IOC CED,I CHALL NUT EMPLOY PERCOND CUBJECT TO WORKMAN'S 0011MMATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRSNG OR=CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERSOMAANCE OF THE WORK FOR WHICH THM PERMIT M ISSUED,1 CHALL EMPLOY PERSONS VLOJE'CT TO WOMMM'S CO/dPOICATION LAWS OF CAUFOMOA.' TN's APPUCAUT MUST CALL 24 HOUnO CJ ADVANCE POR ALL R2GV=OIBCPECTW"3 AT I20D14M.9423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Clorw Xa— Two ThN �-1a�ro �eC�o°i� S+ D.,. PLOT PIAN Crew to Se.I.i 1. HAWS OF VrMETC OR ROADO HEAR'EST TO OR DOUNDHO THE PROPERTY. 4. LOCATION OF HOUSE CEWAGE DISPOGAL QYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.WVMIG OtAAENOXONO AND NORTH DIRECTION. EXPANSION OF SEWAGE D12POM SYSTEIAG. 3. DOEENCtONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLB WITHM RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES.MGCLUIXNG COVERED AREAS CMH AD PATIOS.DMVEWAYG.AND WAUKG. ON THE PROPERTY OR ADJOIKNG PROPERTY. .... .. ........... AP ON BACK ............... ............. ........... ........ ................. .......................... ...................... ............. ...... DEPARTMCRIT UOE ONLY / ApO*mtbn A~ed Dy_--m D.. 3 a- ( (. Am. GmA kupowlen Dy Date Puna ItnP.eNen DT Dom. D..trucoon kwro.etlen Bt Det. Cerement.: ACCOUNTING ONLY: AIDI FACS PE CODES FEE Imm AMOLVIT naffTTED CH2CK,ICA8H RECEIVED BY DATE PER T/SERVICE REGUEDT NUMER INVOICE � 11 13D