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APPLICATION FOR WELLfPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388,304 EAST WEBER AVENUE,STOCMN.CA 95201388 (208)4883420 NOWAEFUNDABLE PEAMIT EXPIRE! 1 YEAR FROM DATE ISSUED APPLICI�empble In Tralinstel JOAQUIN CO N HERE E MADE TO THE SAN JOAQUIN COUNTY FOR A PETiN11T TO CONMUCT ANIVOR INSTALL THE WOFK DESCRIBED.THIS APPLJCATION la MADE IN COMPLIANCE WITH BA JOAOUIN COUNTY OEVElAPMENT/T.,RLE,CHAPTER 81116.3 AND THE STANDARDS OF aµJOAOVIN COUNTY PUBLIC HEALTH SEFIVICEB,ENVIRONMENTAL HEALTH DMSION, JOB ADDRESWOR APNO �J(: —�- CRY �A A� /o'2-- - :CA PARCEL BOFJAj'N► oWINFJ{'a NAME'P/l�.11[l : A r I f/ Y�`A/� 99 PPdL�Jsa{ C ADDIEea��7 2r S.�(j/ Wjl� �dT L-j 2 PHONE► CowrRACTOR_(�_�s ial>;l/ ( Q,�11.- - H AODNE80 LIC► ��PIpNE/ �� 81N1 CONTRACTOR,_ ADDRESS UCTYPE PHONE OF P. {il NEW WELL Cl AEFIACEMEM WELL ❑MONRONNO WELL s ❑OTHER_ ��•�--j��-��...� ,(L•J.,INSTAWTION ❑WELL JON'SST7EM REPAIR ❑ CROSS-CONNECT REPAIR ❑VAPOR E%TRACTION UE{L f RYPE OF PUM1h �❑ W H-P— DEPTH PUMP IET�FT. FIRST WAFER LEVEL / ❑ ❑OUT.Or•6ERVK:E WELL ❑GEOPHYSICAL WELL SH ELL E ❑ SOIL ROIG B DESTRUCTION• {MTENO tE YPE OF WELL ONSTRVCTION 0 RCATIO NS ❑INDUSTRIAL AOP[N BOTTOM TI DIA.Of WELL EXCAVAON a DIA,OF CONDUCTOR CAaRTO A p D DOME ETICMiyATF I❑y GRAVEL PACK/SI.•E TYPE OF CA81Np/STEEEAVt�re E L � DIA.OF"FELL CAa1NO !� 19 IJ oRNEN DEPTH OF GROUT SEAL f L PUSl/CIMVNICRAI SPECIFICATION �(7 ❑SSIIOATION/AG ❑OTHER GROUT SEAL INSTALLED BY/y r)"4 S ORDUT BRAND NAME R ❑MOWTONNO GROUT SEAL PUMPEb � : Yw ❑No CONCRETE PEDESTAL BY DRRIER:❑yw [IN. S A►PMX.DMH LOCKING CHEFTE14 SOXlSTOVE RPF s RROroaED CONSTnucnONIDRILLNo M(►Hp D: MUD ROTARY_ AIR ROTMY AUGER_ CABIE�_OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPIJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE N4TH BAN JOAOUM COUNTY ORbINANCCi,STATE lAYJO.ANb RULES Ila { REGULATIONS OF THE SAN JOAQUIN COUNTY- HOME OWNER OR LICENSED AGENT'S BIONATURE CERTIFIES THE FO110WMI0:•I CER,FY THAT IN THE PEIIFORIAANCE E THE WOIK RUL SAM { THIS OLLOPfF*A10IRSl1ED,i SHALL NOT EMPLOY PERSONS SUBJECT 70 N'OIIgNAN'B COI.IPSNSATION LAWS OF chuFORNIA.'CONTRACTOR,MING OR SUS.0 RACTVQ NGNATINE CLRTIFIE THE FOLLOWSop HOM •I CERTIFY THAT IN THE PERFORMANCE Of THE WOW FOR WINCH THIa IEIOAR la ISBUPJ,I SHALL EMPLOY PERSONS SUBJECT TO WOnpNAN'■COMFQ/BATWN LAWS O I CAUFORMA.' jA/nPPOLICrAN.T/J�/U�BT�CJI.LL M NDURa IN ADVANCE MR ALL REOUSIED INSPSCCMNN4 AT MINI 4404422.COMPLETE DRAWING AT LOWER AIEA PR,'C.CDE•D., C SIBnAd K-yI?L�+--A+LL-iffAc _ThN�w++f On.y�'�-.'•�/r PLOT PLAN Kk—Ie SmdN 0-00 le 1. NAMES OF FTREE78 OR ROADS NEAREBT TO OR BW OUNOO THE PROPERTY. 4. LOCATION OF HOUSE BEWAOE o1SIVSAL SYSTEM OR rMpo"b 2.OUTLINE OF THE PROPEIITY,OIVRNO DIMENSION/AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEM, 3-DIMENSIONED OVTLINF.fAND LOCATION OF ALL EXISTRNO AND PF40POSED S. LOCATION OF WELLS WTTHIN RAD"OF ONE STRUCTURES,INCLUNNO COVERED AREAS SUCH AS MTIOB,DRIVEWAYS,AND WALKS. HUNDRED FIFTY FT. ON THE PROPERTY On ADJOINNG PROPERTY. ....:.......: :... .' ...:...... ....'....> . .i...: I i ....... ... .: r •.....i...... ILI .:..• T. : .............:.....a... .. .<.. :.. .i. y ...:.....e....:. . :.... ............ ......a .. ... n ... ...s... .;..... ; ', .. .I .. s. ; .... _ _ 21. TALI"'tlt ajy :r DEPARTMENT USE ONLY AP 11-11—AAF4led SY_ _Anr GI A In.w lon By �lrl�!/ DTI.•,� ,3l-�b p—,InP-0-By br1.�ellon Inopeonan eT WIA C� cemm.RA: Accrvsnnp ONLY: AIOI FACE 1 � ve COD" FEE INFO N40UNT REMITTED - /CASH RECRVED BY DATE PEIINNT/BBRVICE REQUEST NIlw illm ✓`RFVq/CE 1 �� P7d'D/% 9 O a�oi r