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APPLICATION FQR WELLIPUMF P€RMIT 3N JOAQum COUFIT'! PUBLIC AEALT4 SFRIC± F^NYtRc1%mE.a1 !- HEALTH 91VISION. P Q SO:t W, 304 EAST WESER AVENUE:, STO" TON, CA Wx71388 (209) 460-3420 �. .10I4•,FiEf[1HgABLE HERMIT EXPIRES 1 PEAR FRQp BATE ISSUED APP[.iCATION 19 HERE$Y MADE TO THE ShF!J^ ICompfeta IR �rlpftcsl�l 1. ..AQU^'°'-,AUNTY FOR A P£F.MIT TO CONSTRUCT ANDIOR INSTALL T14E WORK DESCRIBED.TRIS APPLICATION IS MADE IN COMPLIANCE WTTH SAN I JOAOUIN COUNT,DEYELOP'.MENT TITIE.CHAPTER;-11 15.3 AND THE STANOARDS OF SAN JOAQUI.f COUNTY PUBLIC HEA 7N sERv!C�S.ENVI. L c RONMENTAL HEALTH DIVISION. JOB AODRESSIOR APNa �TiO �_ v•7 ;J . CITY - PARCEL SIZFJAPFIA OWNER'S NAME PHONE R CONTRACTOR .� ADDRESS I� LICO PHONE ecoRACTDR135 0 ion{� �• 'w I\,1OnPtAe L1C4 rrTG PfiOIIE/ Y/ TYPE OF WEUJPLIMP! ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I �' ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS•CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑ ea Naw❑Rolr H.P. DEPTH PUMP SET FT. (TYPE OF PUMP) � FIRST WATER LEVET. O _ u i✓ •Z;t;T-OF-eE�V!CE WELL ❑ CE7P!-iYSICP,L WELL.7 t]p SOIL/ BORING, B ❑DESTRUCTION! 1NFEHbED USE TYPE OF WELL CONSTRUCTION APECIF+Cl,TIONS .t D INDUSTRIAL ❑OPEN BOTTOM DIA*OF WELL EXCAVATION DIA.OF CONDUCTOR CASING lJ DOMESTICIPRtVATE ❑GRAVFL?ACriSI2E_ TYPE OF CASINGISTEEUPVC DIA.OF WELL CASINO O � ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL � 6T'ECIFICATION R 11 lRRIGATIONfAG OTHER GROUT SEAL INSTALLED LtY !� GROUT BRAND NAME c ❑ MONITORING GROUT SEAL PUMPED! ❑y— APPROX. ❑Nn RETE PEDESTAL SV DRI [10. 4 APPROX.DCONCLLER!❑YAs g 21. LOCXING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIDMI-INO METHOD: MILD ROTARY AIR ROTARY AUGER CARLE OTHER I HERESY CERTIFY THAT I HAVE PREPARED THIS APPUCATMN AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN:'.IOAOUIN COUNTY ORDINANCES.SLATE LAWS,AHO RVLE9 AND REGULATIONS OF THE SAN JOAQUIN COUNTY. "Out OWNER OR LICENSED AGENT-B SIGNATURE CERTIFIES THE FOLLOI.MNG!'I�CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMtT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-4 COMPETIqIATTON LAWS OF CALIFORNIA_' CONTRACTOR'S HIRING OR SUB-CONTRACTING SLGNATURE CERTIFIrS THE FOLLOWING! 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED-1 SHALL EMPLOY PERSONS BULUECT'TO WORIONAN'S COMMJIIAT!.Or! LAWS OF CALIFnRNIA.- T"F APKJCANT!HU CALL.A�C'4+4 Au JJJJ�. .....r...rp YC�FfSft A.._�tn,•.gle+i eyf�o�^�.�....�AT 7^..--a::^. ^:":'I••ei_ .. ;-:".-•.e'!":C. .. :LDT FLAN{Draw to Sr.±+wl Scala 1- ""tE3 OF STREETS OR ROADS f-MAPEST TO UI'3C-ANDING THE PPOrVTr,. tt' f. 2. DLCCA-!ON cF'iOUFF e£VaAGC OtRf�oeAi;y^TzF.i 7^OUTLINE OF OF THE PROPERTY,GIVrNO OfMENSrp Ho.:t';}NO. FI OIRECTION• EXPA':ON OF%F.WAm3E VI BP!'?AL SYZTcY,4: 3. MMENSIONED 7UTUR7S AND t!-C.ATIO:I OF AAI_EY.iS7TM(,AML`PROFOrro �'JI,•i�!C,y rF;',"U-8"'1T'HiFf 7A Df118 CF Ct+ �'.:?17RFD'{i 1'f STRUCTURES,7NCL;!1)!NG COV:P D AREAS 3UC;t A?;�ATTOS,MISVEWAYS.AIND 1vALI(S. C'S IF I'.1J '4T-= OR%',DJOFZ!t-0G .M _ .... .. ... .... - - y 3' �* DEPART!:4EN7 UBE 016.4-r �f 7rI� Arne. tS '' Date Rrmn r—pR•alnn ay - • RY Jain G` rb 10.2d 4Ua�?k�ain fC. 8chadl�ced �..� 1ZZ3-��p-- A Y Oifi Alb• FACtr AMOUNT RIMTTFD CNECKSICASH RECFPVED!3Y BATE ;j, PSIMITMERVICIE REOUEAT NUMBER INVOICE I2 sI -4c T� "d 112'-��` '