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APPLICATION FOR WELI(PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />R,O, BOX 388, 304 EAST WEBER AVENUE, STOOMN, CA 95201 88 <br />3 (2091 466-3420 <br />L / <br />NOM-REFUIIDAILE PERMIT EXPIRES I YEAH FROM PATE ISSUED <br />(CBIApI•IB IB Tr*Rcati} <br />APPLICATCN IB HEM BY MADE TO THE BAN JOAUUIN COUNTY FOR A PERMIT TO CONSTRUCT ANONR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TrTL.E,,CC/H�HAFITER O-1116.3 AND THE STANDARDS Of BAN JOAOUIN COUNTY IUC H LTH SERVICES, ENVIRONMENTAL HEALTH DIV.MON. <br />JOB ADOIESSRJO API// r+ V' V S C:. CITY / PARCEL <br />ERSIZE/AWMI �^T <br />OWN'S NAMERE <br />�j 1. cl ADDRESS f -E.. QC LCA PI INE Jam 7 <br />��CONIRACTOR� ! A L f n r AGGRESS I% '�r`J• LICf 17OHf <br />Sue CONTRACTOR ADDRESS LICE MFONE f <br />TYPE OF WELUPUMF�. t WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL • ❑ OTHER_ <br />❑ INSTAi LATION Q WELL SYSTEM REPAIR Cl CROSSCONNECT REPAIR ❑ VAPOR E%TFNCTION WELL F <br />ITYPE OF FRI►IPI <br />❑N -13K ll H.P. OfPTN PUMP SET FT. FIRST WATEA LEVEL <br />❑ OUT -0F -SERVICE WELL ❑ GEOPHYSICAL WELL f ❑ BOIL /JOISNO <br />❑ DESTRUCTION: <br />INTp•Dm UU TYPE 6F WB1 CON TION SP cm NB <br />❑ INDUSTRIAL <br />�y �❑ OPEN BOTTOM DIA. OF WELL E%CAVATON ( MA. OF CONDUCTOR CASINGD <br />tiny DOMESTCRIYVATE ZO-SRAVEL ►ACKISRE TYPE OF CASINWI TEELOPW DIA. OF WELL CASINO <br />❑ PUBLCMUNCIPAL ❑ DRIVEN DEPTH OF GROUT SEAL / _ SPECIFICATION •VR <br />❑ IRRIGATONTAG ❑ OTHER GROUT SEAL wSTALLE,D BY 7e �C _ GROUT BRAND NAME <br />❑ MOwTONIxi f /� I/ YZi�/� GROVT REAL RIMPED:`C/Yw ❑Nn _ CONCRETE KPESTALB�W <br />Y ."(3Yr a—. <br />APPROX. bdli" 1 "f/ LOCKING CHESTER BOX[VTOVE PIPE A <br />PRO►oBED CONSTRMTIONIDFSUDlO METHOD MUD MTAFIY_K— AIR ROTARY AUGER__ CABLE OTHER <br />I "E%BY CERTIFY THAT I HAVE REPINED THIS APPLICATION AND 1HAT THE WOW WILL BE DONE M ACCORDANC•: WITH SAN JOAIMN COUNTY ORDINANCES, STATE LAWS, AND MITE <br />REGULATIONS Of THE SAN JOAGVIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR H <br />THIS PEFMIT IS ISSUED, I MALL NOT EMPLOY PERaONa SUBJECT TO WORKMAN'S COMPWSATON LAWS OF CAL WORNIA.' COMPACTOR'S HIRING OR SUBCONTM.CTNG SIGNATURE CERT e <br />THE FOLLOWING; ' I CERTIFY THAT M THE PERFORMANCE OF THE WON( FOR WHICH THIS PERMIT IS ISSUED I SHALVEMPLOY PERSONS SUBJECT TO WORIOAAN'S COMPUOATION U F <br />CALIFORNIA.- <br />. RIE APPLICANT/1MUST CA 74 IOW IN ADVANCE FOR ALL FRONIF INSMT /pr FO AT 12011144111-2421t. COMPLETE d1AWM AT LOWER AMA P OWEEDDD- � -/7 <br />aIOnMI x LI - l . ffja' Tlne L H� Mn �� / T <br />PF -OT FIAN 10— Ie SSM•,) ASM• <br />1. NMRE <br />AE$ OR STETS OR ROAD$ NEAREST TO OR SOUNDIHO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISIOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY, OIVRNG DIMENSIONS ANO NORTH DIAECTKIN. EXPANaON OF SEWAGE DISPOSAL SYSTEMS, <br />J. DWFNSIONEDOUTLINES AND LOCATION OF ALL FXIRTINO AND PROPOSED $. LOCATION OF WELLS WRTMN MANS OF ONE MARIRED FIFTY PT.. <br />STRUCTURE B, INCLVDWO COVERED AREAS BUCH AS PATIOS, DRIVEWAYS, ANO WALT 9. ON THE PROPERTY OR ADJOINING PfOPU{Tl'. <br />DEPARTMENT USE ONLY <br />A-11.. •n A—*,.d By l � %6 •(C DMe % �L/�- -7 <br />r <br />Oreut IMpe•11•R BTS .L• ORDS / (( j P-0 hu Pxtbn By Date <br />bstruatbn In•pstiyi <br />T <br />IL4 1 O 7 1 9.. <br />Da• <br />ACCOtWrING ONLY, AOI FACE <br />_ <br />Pr. CODER FQ INFO AM.L.T .TIED HFCIUF ASN RFCBVED BY DATE <br />�PB�IAT159FVIC■ R[GUEST NIMB91 <br />1 Ci <br />