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APPLICATIOR FOR WELLIPUMP PERMIT <br /> SARI JOAaU1M COUNTY PUBLIC HEALTH SERVICES <br /> EMVIROMMEMTAL HEALTH OIVISIN <br /> P 0 BOX 388, 445 A1. SAN JOAOUTAf ST, STOCXTOAJ,CA 9520 388 <br /> (209) 458 3420 <br /> n0f]REFUNDABLE PERMIT EXPIRES 1 YEAH FROM OATE ISSUED <br /> [Comptoto ID Tft?r=tcl <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT T`ITLE/.CHAPTER <br /> /8 1115 3 AND T14CSTANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> JOB ADORESSMR APNd ? G ��!PYG e P /e CITY G�-/D <br /> PARCEL SIZFIAPNs <br /> 7OWNER'S MAME Ce(ZA I rl i (ecc 1,tyi 1 -�- C�''JL1if"E 11:ti,t.f. ADDREss /Z l el" p f �d C � FHDNE s_ <br /> L�Dr?I' I AW��IS' e s��7-^V �7 I_-y <br /> y�1 'Jff11 Q(�1VF-T tl' j v, L <br /> $68 VJNTRACTDR 1^ ADORES$ LQ C/S JRA}{fid AMONE d.J V`Ll <br /> TYPE OF WFLJPUMW EW WELL ❑ REPLACEMENT WELL MONITORING WELL 0 U:5-f——���}� ❑ OTHER <br /> ❑ INSTALLATION © WELL SYSTEM REPAIR ❑ GROSS-CONNECT REPAIR I ❑ VMOR emuk TION WELL s ,� <br /> ❑New❑Re , H P DEPTH PUMP SET FT FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑ OUT-0E-sERVICE WELL ❑ GEOPIIYSICx WELL 0 ❑ SOIL SOFUNG S <br /> ❑DESTRUCTION <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFACATIONG A <br /> ❑ wDUSTMAL N0/OPEN BOTTOM ELL DIA.OF WEXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOIMESTWdMVATE .{^,GRAVEL PACXJStZlETYPE OF CASING/STEEUPVC VG —Av� DIA.OF WELL.CASING <br /> ❑ PUBLC/MUMICIPAL ❑OEgVEN DEPTH OF GROUT SEAL (g D SPECIFICATION <br /> ❑ tRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY Specjra YY) GROUT BRAND NAME g <br /> 'AMONITOHING / GROUT SEAL,PUMPED Ely")Rt- I��h'��'�� CONCRETE PEDESTAL SY DRILLFFL Vo ❑Na S <br /> APPROX.DEPTH�-.-- _. LOCXING CHESTER BOXI$TOVE PIPE LQ 4-"Y <br /> PROPOSED CONOTRUCTIONfDROWNO METHOD MUO ROTARY AIR ROTARY AUGER CABLJ: OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARFD THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SMI JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY HOME OWNER OR LICENSED AGENT 9 SIGNATURE CERTIFIES THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT Is ISSUED I SHALL NOT EMPLOY PERSONS SUBJECT TO WORLOMAN S COMFEJIOATION LAWS OF CALIFORNIA- CONTRACTOR'S HIRING OR$U11-CONTRACTING:SIGNATURE CERTIFlE$ <br /> THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEAUrr IS ISSUED L SHALL EMPLOY PERSONS SUBJECT TQ WORIOLIAN G CDMPENGATION LAWS OF <br /> CALIF ORNIA NE APPLICANT MUOT CALL 24 HOURG IN ADVANCE FOR ALL REdLW1ED IN6PECTIONO.AT 12001 AOO.i623 COMPLETE DRAWING AT LOWER AREA PROVIDED <br /> 1 Sloned X Gal-I1/I 21ti� tip,-.. C,— _ ' <br /> J�I `— Tlda <br /> �G PLAT PLAN Mr. ,e Scow Saaa to <br /> I NAMES OF STREET$OR ROADS NEAREST TO OR BOUNDING THE PROPERTY < LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2 OUTLINE OF THE PROPERTY GIVING DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE OISPOSAI.SYSTEMS <br /> 2 04MENGIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6 LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT \ <br /> STRICTURES INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS <br /> AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY (C <br /> R <br /> R <br /> DEPARTMENT USE ONLY <br /> Appiketlon Accepted BY <br /> Grout VMPee:tIon Br Date Ptanp Inaoacul BY Onto <br /> Oeamtatkm Imamd.n BY Det. <br /> Camtnarca .� /'�5 d� <br /> ACCOUNTING ONLY AIDA FACJF <br /> PECooes FEE INFO AMOUNT REMITTED CHEC"/CASH I RECEIV BY DATE NNATISERVICE REQUEST NUMRIER INVOICE <br /> QC <br /> 0 3 95 x. 44 Slav <br /> o � <br />