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h )PLICATION FOR WELL/ UMP PERMI1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEAL H DIVISION 1 304 EAST WEBER AVENUE, ST CKTON, CA 95202 (209)468-342 11 NON-REFUNDABLE PERMIT EXPIRES 1 YAR FROM DATE ISSUED (Complete In Trip? etel APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR 'STALL THE WORK DESCRIBED.THIS APPLICATION IS MAOE IN COMPLIANCE WRH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN C LINTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. {/7 JOB ADDRESS/OR APNI '74�"��/T� CITY ; I PARCEL SIZEIAPNI�`�'�� r� J 4 +� '� C/T PHONE R 1 ~ OWNER'S NAMEl/I. •'S-' Y" ADDRESS Cf� CONTRACTOR ADUREB �j,E—t: 2 ��lS` LLCM +�' PHONE I 10 SUB CONTRACTOR ADDRESS LIC' PHONE 1 TYPE OF WEU.IPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 1t ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNEC t REPAIR ❑ VAPOR EXTRACTION WELL S J ❑New❑Repelr H.P. 1 DEPTH PUMP SET FT. FIRST WATER LEVEL Q r1YPE OE PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING R ❑DESTRUCTION: I. INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I. �57 OLA.OF CONDUCTOR CABINO O ' I ❑ DOMESTICR'RIVATE ❑GRAVEL PACKIBIZE TYPE OF CASIHJOISTEEL/PVC OIA.OF WELL CASINO D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL IN { BPECIFICATION R �IR ❑ IRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY { GROUT BRAND NAME Ly MONITOPJNG77,,�� --77 GROUT SEAL PUMPED: ❑Yw F-1No'�'�jVwj� CONCRETE PEDESTAL BY DRILLER:❑Yw ❑No S APPROX.DEPTH Z Z� r LOCKING CHESTER OXISTOVE PIPE S PROPOSED CONSTRUCTIONRRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER +/ I H£q£8Y CERTIFY THAT 1 HAVE PREPARED THIS AP'UCATION AND THAT THE V40FK WILL BE DONE INA CORVANCE HATH BAN JOAQUIN COUNTY ORDINANCE8,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOVIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERtl IES THE FOLLOWING:'I CERTIFY TNAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMMNSATION LAV41 OF CALIFORNIA.- CONTRACTOR-8 HIRING OR BU13-COMPACTIP40 SIGNATURE CERtIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 1 SUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,- THE PPUCANT MUST C 2 HOURS IN ADVANCE FOR ALL REQUIRED INSTIONS A 120S11e8J423. COMPLETE DRANRNG AT LOWER AREA PROVIDED. - Signed X IISL, f _ ___Tltle Dote PLOT PLAN(Grew to Saelel Scale 'to- 1. e1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERLY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTEMS, 3. DIMENSIONED OU`TLINF8 AND LOCATION OF ALL EXISTING AND PROPOSED - S. LOCATION OF WELLS WTTHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. DEPMTMENT USE ONLY LJ L ae Dale Ar" ApplleNlon Aaer0ed By Grain Impecllen BY Deee�?' r R�mP ImPecflen 8 Oftp Oete D-1-11..lnepecllan BY CemmerMf: .4? ACCOUNTING ONLY: AID# FACT D PE CODES FEE INFO AMOUNT REMITTED CHECaASH RECEIVED BY ATE PERMITISERVICE REQUEST NUMBER INVOICE cp G� ¢ c zs �� a Z Pub.Health Serv.-EnvirG.173(1197)