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1 p, '�;; •LA`�J; -/ APPLICATION FOR WELLIPUMP PERMIT j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES '" �" °` • ENVIRONMENTAL HEALTH DIVISION "( P 0 BOX 388, 445 N. SAN JOAOUIN"BT, STOCKTON, CA�96201-388 I� "- -- (209) 488.3420 11'Y NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 5' V (Complete In Trlpliub) APPLICATION IS HERE BY MADE TO THE BAN MAGIAN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAGUIN COUNTY DEVELOPMENT TITLE,CHAPTER( 1111?5.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOBADDREGmn.A!{�P�NIJLAA 1C+�-�,r I.___�_i ,� Cm, J-RAC,!l G' PARCEL BRE/APNJ OWNER'S NAME / JVV / j 6 . ADAOOHWE6i6 86 N R14-rCw�i/{// NCJF10.1 .7��PHONE I ZoolNy3� �J�—Q`y-I(-�I CONTRACTOR JJ%r0(� PHONE I g�•! DOJ O>/.j//V/�J/� BUB CONTRACTOR 'II F�1I I�it Au t, t ADDREB6I�o La.IQI1�1 �.NI+ccY�UCJ'�BZ39y PHONEJSILJ 661,3 TYPEOFWELLJPUMP.R ❑ NEW WELL' ❑ REPLACEMENT WELL ❑ A10NITORINO WELL ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I (TYPE OF PUMP 13Naw❑Repelr H.P. DEPTH PUMP BET EVE FT. FIRST WATER LL 13OUT-0F-SERVILE WELL ❑ GEOPHYSICAL WELL J BOIL BORING g 1' ❑DEBTMILTION: •�„"j+ INTEND---- I ' TYPE OF WE{L CONSTRUCTION SPECIFICATION 8 _ A �V 13 INDUSTRIAL I' 13 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING' D / ❑ DOMEBTIC/PNVATE 13 GRAVEL FACMBRE TYPE OF CASIN42/6TEFLNVC DIA.OF WELL CASINO ' O ❑ PUBULMIUNICIPALI ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION g (� ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INBTPLL�\Da�BY GROUT BRAND NAME E \� ❑ MONITORING 'O ORI)UT BEN PUMP£0:YE,I Ys ❑Na CONCRETE PEDESTAL gy DRILLER❑Ys ❑Ne S APPLro%'DEPTH LOCKING CHESTER BOXRBTOW PPE PROPOSED CONSTRUCII lURHWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERI) I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN K)AQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED;I SHALL HOT EMPLOY PERSONS SUBJECT TO WORMMAN'B COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES _ THE FOLLOWING: `1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR"WH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO W,,MMM,,,COMP7HA N LAWS OF CALIFORNIA.'({THE APPU AMT MUST C�/�\p IIR81N AOVANC[FOR ALL REO ( TMN I AT DIOS)jpll 2n. COMPLETE DRAWING AT LOWER AHEM PRM ED. / NEIw x l 0 1 ,.•�. U FIRM; C-e""'""'� TM.t 1 Y'l'1,�' I I'\�'1-t'Y/ T YI (Z-3. PAT PLAN ROPE to BpNal eaale�-to J-y I 1. NAMES OF STREETS OR ROADS NEAGIVING DIM TO OR BOUNDING THE DIRECTION. 6. LOCATION OF IIOUBE ESEWAGEOISPC OIBPOSTE SYSTEM OR PROPOSED i 3. OUTLINE Of THE OUTLINES AN DIVING DIMENSIONS AND NORTH DIR OPOSE EXPANSION OF SEWAGE mSPoBN SYSTEMS. 3. DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING PATI AND PROPOSED 6. IN THE PR OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ' BTRUCTUREB,INCLUDING COVERED AREAS SUCH A6 PATIOS.DRIVEWAYS,AND WALKS. .ON THE PPAPEI(TY OR ADJOINING PROPERTY. i s �N!073��t71 —I Z , If d I 11`11!#+ 3aa� a /�\ IL If i 1f p I� 'M`" -�• d-e�aLadAe;MrPlfSmhYeTj4 DEPARTMENT WE ONLY x Nplketlon Aeaptatl BY I �TIL!!%/� / ��/5� / Dtla !/ G Ara` Grant lapap By I Det. Pump InM mUon By one I Druuetla HNoepBa By One CemmaN: +. li ACCOUNTING ONLY:? AIDJ FACT I, /�� PE CODES FFE INFO AMOUNT REMITTED C/N q_"MABH RECSWD BY DATE PE MITR IETME REQUEST NUMBER INVOICE II t I r