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1PPLICATION FOR WELL/PUMP PERM pPIWM--V SAAQUIN COUNTY PUBLIC HEALTH SEES Fkec ENVIRONMENTAL ON 304 EAST WEBER AVENUE,TOCKTONALTH ,CA 95202 Nov 6 200 , NONREFUNDABLE PERMIT EXS 4 YAuR FROM DATE ISSUED SAN��HESHE pC)IJINONDE SIDt+ (Complete In TrlpRoel p1191.M�N1AL JOAQUI TION IS Y DE EL MADE TO THE BAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDNR INSTALL THE WOR(DESCRIBED.T1G6 APPLICATION18 MADE IN COMPLIANCE MT 15.3 AR JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODgEe8/0fl APN/ S L S PAG J )= A1J /�✓tT CRY C STG1C7vJ/1/ PARCEL BIZE/APNe /Vg-lee-61 OWNER'S NAME S�1/Y_1c.-�qL!/�//>�L7''j L'•:7LLtG�' STIR/ /5*S ADDIIEBB F JJd PHONES ZU% �S CONTRACTOR CZ-+RA� L�✓t_jL //L�C� ADDRESS z�� l/4.A'Yf� IICI-�7/S7r fJ RIONE0 PE)7 y(�t'_J SVB CONTRACTOR ADDRESS 7 UCS PHONE ` TYPE OF WELLIPOMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL n ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F ❑New❑Repdr H.P. DEPTH PUMP SET FT. FIR" LEVEL J RYPE OF PUMP) —_ O ❑ OUT SERVICE WELL ❑ OEOMYSICAL WELLS BOIL BOMNG TEST A�Ae//L'4 DESTRUCTION: yLZ T B INTFNOE0 USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATIONA 11 DIA.OF CONDUCTOR CASING O OOME9TICR'RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC 11 PUBLIC/MUNICIPAL ❑DRIVEN DIA.OF WELL CASINO D RRRRRRyyy---yyyMONITORING GROUT OF GROW SEAL SPECIFICATION , IARIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY R T BRAND NAME E APPROX.DEPTH GROUT SEAL PUMPED: [IY« ❑Ne CONCRETE PEDESTAL SY DRILLER:❑ym []NO S LOCKING CHESTER BO%/STOVE PIPE PIIOPOSED CONSTRUCTIONMIBWNG METNOp; MUD ROTARY_ S Alq ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MTN BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES ANO REGVUTIONB OF THE SAN JOAOVIN COVNTY, HOME OWNER Oq LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERIORMANCE OF THE WOW FOR WHICH 0 THIS PERMIT IS ISSUED,I SMALL NOT EMPLOY PE HOME 8 JECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA: CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CEWIFIE6 THE FOLLOWING: •1 CERTIFY THAT IN THE PERPORMA E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA.- THE ApP11CANT MUST CALL fI HOlme ANCE On ALL REQUIRED INSPECTIONS AT 120014"J1%E. COMPLETE DRAWING AT LOWER AREA PI10VI0 SlSrwd X TIIIe Z�iQEiy7" N IDrw.le Be WI •Le 1. NAMES OF 6TSeel. STREETS OR ROADS NEAREST TO OR BOUNMOT DING THE PROPERTY, 2. OUTLINE OF THE PRIGIVING DIMEN6mN9 AND MOWN DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISP09Al SYSTEM OR PROPOSED 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION F SEWAGE THIN RADIUS eS OF ON STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS,OMVEWAYS,AND WADI S. LOCATION OF WELLS WITHIN RAmUB OF ONE HUNDRED FIFTY FT. ON THE PROPERTY Oq ADJOINING PROPERTY. Sc'E A77-4G'fir•/Yl-/V'TS W. Y �oENT USE ONLY APPB..rtee AeepleA By " `� D.1. �' Me. v... Orem Impmnen ey One R P leepemlen BY Ons Deems 11..IMPecllen Br One Cemmeme: ACCOUNTING ONLY: ALO/ FACS PE CODES e1GE 1 O AMOUNT REMITTED CHECK ASH RECEIVED BY DATE PERMITAHIFIVICE REQUEST NUMBER INVOICE s'F y q7rC5 ��111 353 8_I 3 Pub.Health Se".-Enviro.173(1/97) //I" f MTn ,LyLL f IL E COPY