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APPLICATION FOR WELLIPUMP PERMIT D D SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION Rd, BOX SM 364 EAST wr=BER AVENUES STOCKMR CA 35261388 (109) 469-7420 NON-REFUNOAILE PEIMIT EXPIRE! I YEAR FROM DATE 133UED APPLICATION IS HERE BY MADE TO THE SAN JOADUN COUNTY FOR A PERMft TO CONICRiUCTAND/OR p *9TALL THE MW DESCRXlED. THIS APFi1CAMN I8 MADE IN COMFUANCE V H SI.N JOADLPN COUVT'/ DCirF1 � Tt� C� ER 91115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PURUC HEALTH SERVICES, ENNIgNMEMAL HEALTH Dl,. 0N. JO/ AOOAEB xw ,RINE 5 CT , {L` �]61:�s PAM_FL,9F2F//4R�f OWNER'C MIME AODAESS "T 1 C- IFICJiPF',ONE • t �}�) CONTRACTOR , ` S A[KAIE88k LX:f fSAONE�V SUS CONTRACTOR.^11 9 LPCA_— PI TYPE OF WELIJPUWP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONFTORNNO NEL..L • ❑ OTHER _T'M03 ❑1 INSTALLNE ATION ❑ WELL ` SYSTEM TEPAIR ❑ CROSSONCT REPAIR Ll VAPOR EXCTq WELL AN—❑Ira a'r H.P._I `� DEPTH PUMP BETXLDFT. FSRST WATEA LE1TL OF PUMP) - ❑ OUT-OF-SERVK;E WELL ❑ OEOFWYSICAL WELL • ❑ SOIL GORING INT wt-- iYP'E OS CON4TAVcTEoN SI¢FICATIONA p❑ INOUSTAAL ❑OPEN BOTTOM A. OF WELL EXCAVATION CAA. OF CONDUCTOR CASING jam' p 'O DOMERTCTFVVATE ❑ ORAVEL PACK/SIZE_ TYFE OF CAAWfSTEEUPVC DMA. OF WELL CASIM D ❑ nomiCA"O"PAI ❑tmvEN DEPTH OF GROUT SEAL 8FECIF)CATKIN R ❑ IRROATIONAA ❑ OTHER GR*STALLED BY SEAL *STABY _ GROUT BRWD NAME C] MONITOINNO GROIfT REAL PRIMPED; ❑ Vr [IN. CONCRETE FEDESTAL BY ONLLER: ❑ Yr ❑ Hs �` S AITMX. D9T14 LOCKOA CHESTER boX16TOVE FIPE- �S PROROSED CONITRUCTIONIORIWNG METHOD: MUD ROTARY` AIR ROTARY AUGER_ — CAILF OTHFT I HEREBY CFMIFY THAT I HAVE PfEPAFED THIS APPLICATION AND T7AT TIE WORK VW1 SF DONE IH ACCOADANCE WITH SAN JOAQUIN COUNTY ORDNANCER, STATE IAYUS, AND RULES RED ULAT10N6 OF THE SAN JOAQUIN COUNTY. HOME OWNER on LPCENSED AGENT'S SKWATU11! CERTIRFS THE F-0LLOWIHO; •1 CERTIFY THAT N i}IF pERFOfSJANCE OF THE WOR`( "WHICH 011 S AND THSFETVAFT IS ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'` CONMPINSATION LAWS OF CARNIA.' CONTRACTOR'S MRR10 OR BVI-CONERKTNO MONATIAIE CERTIFlES TLIF FOLL q; - 1 CERTIFY TNAT N THE PERFOM MANCE OF THE YVOW FOR WHICH TMS PERMR IS ISSUED, I SHALL EMPLOY PERSONS RU lLIECT TO WOAgdN1'I COMFWIAT/0N LAMA OF CALXAJ A.' ! CANT MU •ALL N HOURS IN ADVANCE FOR All RFOUP" IN/FSCTIONS AT IZOII 440-UZ3. COMPLETE DMWNJO AT LOWER AREA PION SIC—d X 1 Tltl. 0.1. I M.OT RAN fDrAw ro Sc.l.� bey ' to I. NAMES 0 STFEETS OR AOAOS NEAREST TO OR BOUND11M THE PROPEATV. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR. pf opogED 2. OUTLNE OF T!E PROPERTY, al~ DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL BYSTEMI, 7. b1ALFNWHED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOBEO S. LOCATION OF WELLS WFTHRAIKUdUS OF ONE HUN[i+ED FIFTY FT. STRUCTUNES, INCLUDING COVERED AREAS SUCH AS PATIOS. CHI Awn—lra ...,..,. a-,.-_---._._.._._�____ Or,:n ir.p.rtbn BY_ C +mrr.rN.: .i .:. t ...... ... .. 5 . ...: ........... .�.. .... L DEAAITkIENT USE ONLY Date PLmp H.p.:Uen A.CCD'..WTINO OMLV; NDA FACI . . . ........ ... . ........ INVOICE .. T .. PUBLIC NEALTF A.CCD'..WTINO OMLV; NDA FACI PE CODE` FEE INFO MMOIINT PF1uITYFD HEC /CASH RECEIVED IY DATE ►jAN.STISEISVICE INVOICE