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APPLICATION FOR WELL/PUMP PERMIT_. - SA(' ?AQUIN COUNTY PUBLIC HEALTH SE' CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE ST [ OCKTON CA 95202 (2059) 458-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TriplkBtel APPLICATION IS HERE BY MADE TO THE SAN JOAOUfN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOFVK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TrTLE,CHAPTER 8-1115.3 AND TIIE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OIVI8tON. JOB AODRE8S10A APN! 0�yyW rO A+A e �d . CITY !!I��'�'�[,��,_,,,, y� PARCEL 812E)APN8 OWNER'S NAME J1 T V M .. ADDRESS �1F-_Sl r 7 j (!G/)I GI C PHONE#-Le CONTRACTOR WeoC(wLt✓d Drt/N AbbRE96 t VI ucs PHONE r 3WIIC `'.+ SUB CONtRACTOR ADORES$ LICl�-i 00 7? PHONE ! f TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL! ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR , ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 J [TYPE OF PVMPI El Now 11Rapalr H.P. �' DEPTH PUMP SET FT. FIRST WATER LEVEL p p ❑ OVT-OF-SERIV`tCE WELL ❑ OEOPHYSICAL WELL! ❑ SOIL BORING g DESTRUCTION: /INTENDED USE TYPE OF W CONSTRUCTION SPECIFICATION! A ' DINDUSTRIAL"�rw= LJ OPEN BOTTOM- 4 DIA,-OF-CONDUCTOR CASING. •��-...:'�.•,�,OFA.OF WELL-EXCAVATION -Y.. ��- -_r�.��- �_� _ ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CABINOMTEELIPVC DIA.OF WELL CASINO p �� ❑ PUBUCIMUNIC6'AL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION 'i g ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E © MONITORING OROUT SEAL PUMPED: ❑Yea [IN. CONCRETE PEDESTAL BV DRILLER:❑Y. [IN. S APPROX.DEPTH i LOCKFNG CHESTER BO%!STOVE PIPE 5 PROPOSED CONSTRLFCTIONMMLUNO MET1400I MUD ROTARY AIR ROTARY AUGER_.-x CABLE OTHER 3 1 HEREBY CERTIFY THAT 1 IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE orTHE wow FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIONATVRE CERTIFIER THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORILMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIPIM INSPECTIONS AT 120011 4400 COMPLETTE�DRAWINmG.A'T!_LOWER AREA PROVIDED.hex SlpnedX TBIa �IrAa LF6i1e C�T �'Yl�T/"�1 �L•Date_ - 4j If I L '[ ii PLOT PLAN(Draw to Sealal Seale I„ 'I. 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY.' 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDINO COVERED AREAS SUCH A8 PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. x T! 4 ' : i� v WG<< . .. .. .. .. .. ....,... .. NO J K .. ...: _ DEPARTMENTUSEONLY..�. ......::....::,... ;.. TELL,.. .i.........:.... ....:.......:......:... /_ _ rj AppAeaflen AcceptedBY m .- ---- _.__ - - -_` ,.,r�•,o-- f:- ,. z-Dat e /S 7 CJ Q,r• .....- I _ T.. -x.�_ :;— ,--• - _�;"yam- =.rr w'" '�.r b Arool Imhee[lon BY 13eat"m0an Imneatlen By i r beta - CemmerNi_ JL fX (M"� QA-r, !�-w�Z-ev\ 1 ACCOUNTING ONLY; AID# TAC/ ©�- PE CODES FEE INFO AMOUNT REMITTED C C IC ASH RECEIVED BY DATE PERMITISERVICE REQUEST NtWu BER INVOICE t j Pub.Health Serv.-Enviro,173(1197) �: