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APPLICATION FOR WELL(PUMP PERMIT - <br /> SAH JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388.304 EAST WEBER AVENUE,STOCIMN, CA 9►5201.388 <br /> (209) 488-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Camplsts In Triplliests) <br /> APPLICATION IS"IRE BY MADE TO THE SAN JgAORltN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.C14AMR 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH Dmalo", <br /> JOB ADDR£SSATR APR# /jam/�//{d{ �/ly� /j "• <br /> .�/�-i4��7,..aL.��; �e Crrrf PARCEL <br /> S12FJAMit <br /> OWNER'S NAMf�Llf_"- f7/ /+Gll.� y {!/' { ' y�l �rllrF•' �4?�f'" <br /> ♦ /"� /�7 �jr� ADDRESS _/ j�f r PHONE t�,�7?�—/I {.,'�i�- <br /> CONTRACTOR_jj �J4� G.- /' �-�/r �i Gt�3'� ' ADtRt£SS� f!: /� tr:l:IC� �CrG.fGr-jilt [ <br /> ^� p � �J PHONE t <br /> SUB CONTRACTOR ADDRESS "�� 7•-'0- - <br /> LICt PHONE t <br />` TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL, ❑ MONITORING WELL t ❑OTHER <br /> ❑INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-COHNECT REPAIR ❑ VAPOR EXTRACTION WELL a J <br /> TrYPE OF PUMP{ D New❑nm h H.P, DEPTH PUMP SET FT. FIRST WATER LEVEL _ O <br /> ❑ow-or-S£RViCE WELL ❑GEOPHYSICAL WELL t BOIL BORING' r r1'IsZ`l� 8 <br /> ❑DEBTRUCTIoN j <br /> INTENDED USE TYPE OF WELL11DIAn0 <br /> CONSTRUCTION SPECiFICAttONi <br /> ❑ INDUSTRIAL OPEN BOTTOM .OF WELL EXCAVATION ,�/� DIA.OF CONDUCTOR CASINO <br /> p <br /> ❑ DOME"TICIPNCVATE ❑GRAVEL PACKISR£ TYPE OF CASINOISTEEL/PVC Al DIA.OF CONWELCASINO <br /> ❑PUSLIClR1UNLCiPAI �0/DRIVEN J� DEPTH OF GROUT SEAL SPECIFICATION //✓� ^� O <br /> ❑ IRRIOATIONIAG ,13,E OTHER i..•j�J~ GROUT SEAL INSTALLED BY �y GROUT BRAND NAME E <br /> A MONITORING 2� GROUT SEAL PUMPED: ❑Y.r p F!er <br /> APPROX,O£PTN,- _ J fZT?A• �iT,// t�/f"' CONCRETE PEDESTAL BY DRILLER:13 Y. Ne� 5 <br /> LOCKING CHESTER BOXISfOVE PIPE <br /> PROPOSED CONSTRUCTIOINTDFOLIIN6 METFIOD: MUD ROTARY AIR ROTARY s <br /> OTHFR AUGER CABLE �P <br /> I HMSY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWNo •1 FOR WHICH <br /> THAT IN THE PERFORMANCE OF THE WOW RK <br /> THIS PERMIT t6 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN•{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'"HIRING OR BUB-CONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TMS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORLDdAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' IST ALL 24 NO RI ADVANCE FOR ALL REQUIRED IFISPECTMNS AT"I Oft v4�csx..-COMPLETE DRAWING AT LOWER AREA PROVIDED, <br /> i BIt"°d X Title L.rt�49Z v/ /T <br /> I D. I <br /> PLOT PLAN LDI.w to Seaw Sod. ' <br /> I- NAMES OF STmt 19 OR"DADS NEAREST TO R BOUNDING THE PROPERTY. <br /> 2. OUTLINE OF THE PROP'ERIY,GIVING OIME"MNs AND NORTH D WCTTON. 4. LOCATION OF HOUSE SEWAGE DXSPQSAL SYSTEM OR PROPOSED <br /> 3. DIMENSIONED OVTLIHFS AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE ONSPOSAL SYSTEMS. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. S, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> ON THE PROPERTY OR ADJOINING PROPERTY. <br /> . . ...:...... <br /> . .:.....:... <br /> DEPARTMENT USE ONLY <br /> Avphc.tten Ae—ted By <br /> ArM <br /> Oroo!k*Pectbn By O•te ^ <br /> tLmP k+.o.etton By <br /> ba.tmctlen MI•eci. lon Ry . Dal. <br /> Comrl,entrSee 9 Lis <br /> ily, x Da1r <br /> ACCOUNTING oNty: AIDC FAC# <br /> PE coats FEE INFO AMOUNT REMITTED CHECKt/CASH RECEVEO SY GATE� P$SN/Tt@t"%nCE REQUEST NUMBER INVOICE <br />' r�2$� • z• at 3 <br /> I <br /> Pub.HBSM Serv.-ERvlro.173("G) I <br /> I <br />