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APPLICATION FOR WELL PUMP PERMIT SAN JOAOUIN COUNTY PUBLI HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, S1 OCKTON, CA 95202 (209) 468-34,0 NON-REFUNDABLE PERMIT EXPIRES 1 EAR FROM DATE ISSUES (Complete In Tripp-stEl APPLICATION IB HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED.TFI18 APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQLpN COUNTY DEVELOPMENT TITLE. TITLE.CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN OUNTY PURUC HEALTH SER/ACES,ENVIRONMENTAL HEALTH DMSION. JOB ADORE88IDR APNI -Z.4`'{1 11)1 K acT 'L[F M A k) CITY I''�O l� PARCEL 8112fJ/jAPN1 �✓]14 c— R'sE T✓ L� U ®DDRESS L e Ay C�+�fi4igNE R vC CONT full - AbDRE88 UC/ PHONEff BUB CONTRACTOR ..., 4 UC!'' �� PHONE/ TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL L�MONITORINO WELL I L ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS—CONNECT REPAIR ❑ VAPOR EXTRACTION WELL e J ❑New❑FWO* H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 4 (TYPE OF PUMPI yy/` - f ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I `_,, 111 SOIL BORING ©vew RUCTION: O U F- SOIL130f2-106, t - Lo ALL. 0 �� INTENDED USE TYPE Of.WELL CONSTRUCTION SPECtFICATIO 11 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.Of WELL EXCAVATtON �{ DIA,OF CONDUCTOR CASING i. 0 ❑ DOMESTICIPRIVATE ❑GRAVEL PACIUSIZE TYPE OF CASINOISTEELIPVC G DIA.OF WELL CASINO _- 2 D ❑ PU8UCIMUNICS'AL ❑ORIVEN DEPTH OF GROUT SEAL ..1I SPECIFICATION R ❑,_,,l/IRRM`ATIONIAO ❑OTHER GROUT SEAL INSTALLED BY A Q GROUT BRAND NAME E W-0 OWTORING GROUT BEAL PUMPED: ❑Yr [IN. CONCRETE PEDESTAL BY DRILLER:Ely. ❑Ne S APPROX,DEPTH LOCKINO CHE8rER OXISTOVE PIPE_ 0.c SZ— PROPOSED Z 5 PROPOSED CONETRUCTIONIDIoLUNO METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HEO&BY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN CORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REOULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENTS SIGNATURE CERT IES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SIUALL NOT EMPLOY NO SUBJECT TO WORKMAN'S COMPENSATION LA OF CALWORWA.' CONTRACTOR'8 HIRING OR SU"ONTRACTMIG SIGNATURE CERTIFIES THE FOLLOWING! -1 CERTIFY T T IE PE RMANCE OF THE WDIeC FOR WHICH THIS PERMrT IB 1 eVED,I SHALL EMPLOY PERSONS SUBJECT TO YYORIOr1AN'i COMPENSATION LAWS OF CALIFORNIA' APPUC M T URS IN ADVANCE FOR ALL REQUIRED INSFWTIORi A 12051 4"4{27. COMPLETE DRAWING AT LOWER AREA PRDVIp Slened X TIft J L FA26 Dn. PLOT PIAN Dow to Sadel Reels •to Q 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, S. DIMENSIONED OVTUNES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WRHIN RAOM@ OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USED ONLY �7 ApPSenVen Aeeepted BY Dne OL,—(- Aroo L-D 17- Uj l OZ Grout Impeetlan BY 1 Dna Pump Impeatton B Dote DeotrMflan hwPectwn By/ ` Dote ACCOUNTINO ONLY; IUD/ FAC/ PE Cobh FEE INFO AMOUNT REMITTED CNECI�ASH RECEIVED BY ATE PEAM1T1eERVICE REQUEST NVNBER INVOICE L1a3 ".� Pub,Health Serv.-Enviro.173(1/97)