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4~ s APPLICATION FOR WELLIPUMP PERMIT'�"� AAN JOAQUIN COUNTY PUBLIC HEALTH SER ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EASE'WEBER AVENUE, STOCKMN, CA 9.+;201388 12091468-3420 IFOR•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Mompists In Trlpl'iests} APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 115.3 AND TFIE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DNISION, JOB ADDRESSIOR APN# ! I / �J4�T Clrv' V IV l rel PARCEL BIZEIAPNI Q OWNER'S NAME ADDRESS ' IGNE# 'j ��/Zdg7 - CONTRACTOR 4I�� ADORES B t�LIC,4*72612 IC#��PHONE I2zo+C/� OUR CONTRACTOR M /!J ADDRESS r 1 T PHONE TYPE OF WELLIPUMP: LSS NEW WELL ❑ REPLACEMENT WELL I�MOf11TORINO WELL#�j ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR © VAPOR EXTRACTION WELL# ❑Hew❑Repalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p (TYPE OF PUMPf - ❑ OUT-OF-SERVICE WELL ❑ OEOPHY61CAL WELL# ❑ BOIL BORING p ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I A .CI INDUSTRIAL ❑OPEN BOTTOM OVA.OF WELL EXCAVATION__ $1 �I--yy�� DIA.OF CONDUCTOR CASINO p ❑ VOMESTICIPRIVATE WRAVEL PACKIBIZE � TYPE OF CASING/STEE OVA.OF WELL CASINO �� p ❑ PVRLIClMVPyCIPAI ❑DRIVEN 5t}'�,� DEPTH OF GROUT SEAL SPECIFICATION IM A �❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BVD ,15?1Icy •I l � GROUT BRAND NAME c MONITORING GROUT REAL PUMPED: ❑YM L7 He CONCRETE PEDESTAL BY DRILLER;❑Y. LSI Ne S APPROX.DEPTH-s - fT:g55- LOCKING CHESTER O�TOVE PIPE S PROPOSED CONSTRUCTIONIORMUmO METHOD: MUD ROTARY AIR ROTARY AUGER- I CABLE OTHER °- - 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WALL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OT THE BAN JOAOUTN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWLNO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'6 COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWINO: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPIXIIATION LAWS OF CALIFORNIA.' THIS, ANT MUST CAI, 34 URS IN ADVANCE FOR ALL REQUIRED INSPECTION@ AT 12*01 468-3422, COMPLETE DRAWING AT LOWER AREA PROVWIRED. X Title s� Date_; PLOT PLAN IO,aw to Be.i.1 Beal. 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,DIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WTTIm"nAD1U$OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, DEPARTMENT USE ONLY Applklrben Aeaeptad By 1' Date_ 7j Ateai Grout Impectien SY Oate P s p lnapmllen BY bate Dealrtmilen Mapeetion BY Date ACCOUNTING ONLY: AID# FAC# PE CODES FEE INTO AMOUNT REMITTED CH /CA6H RECEIVED BY DATE PERMITISEAVICE REQUEST NUMBER INVOICE Pub.Health Serv.-EnYirG,173(3195)