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APPLICATION FOR WELLIPUMP PEI? # i .;AN JOAQUIN COUNTY PUBLIC HEALTH 4:. AVIL_..� ENVIRONMENTAL HEALTH DIVISION P.O. BOX 3W 304 EAST WEBER AVENUE, STO MM, CA MMI- 8 12091468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE C (Complete In TripRuto) 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 WRIT SAP JOAGUEN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111 3 ANO THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/O # CITY \ PARCEL SIZE/APN# OWNER'S NAME ADDRESS PHONE CONTRACTOR ADDRESS #PHONE# � ,,SUB CONTRACTOR ADDRESS --�` LICE PHONE# TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 0 ❑ OTHER 948TALLAVION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONN EPAIR ❑ VAPOR EXTRACTION WELL#� J E _ F' Flu❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL—ff.—/�RYPE OF PUMP] , ❑ OUT-OF-SERVICE WIEU ❑ GEOPHYSICAL WELL# ❑ BOIL BORING g c I❑DESTRUCTION: #NNttT NOED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A t�LJ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D IcMESTic"vATE ❑GRAVEL PACK/SIZE TYPE OF CAGINGISTEEL/PVC GIA.OF WELL CASING 0 © PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R IRRIGATION/AG C3 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORINO GROUT SEAL PUMPED: ❑Yee ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yr ❑No 3 i �APPROX.DEPTH LOCKING CHESTER BOXIBTOVE PIPE g 'PROPOSED CONSTRUCT10N1DItlWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHEF} �—_ 1 I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULE$AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AOENT'S SIGNATURE CEFITIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I @HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF `CALIFORNIA.' H APPLICANT MUGT ALL 24 Ii0 IN ADVANCE FOR ALL REQUIRED INS Ni AT I20B1 41113423, COMPLETE DRAWING AT LOWER AREA PROVIDED, Slgnad X —Title— �' Dna PLOT PLAN(Draw to Boob)Swla to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. W� .,. i Y.n I ...., -..-_. - . ............i., - ., .. ., ., .. .. .. .. .. .. t.; �. c.:.. :.. .... .. .. .. ... �p�. .. .19g ' . 1r .:. ...�.:.. ..:. '. LRCtls!L/ii'S"1_�l'.{1J'i�].Y TN.SERVICE.S . . ... . �,NVi.H.0NMENTAi.HHA H.DIV[ DEPARTMENT USE ONLY f �j .- APPllartkn•Aeaapted_SY_ _ _ _ .-T.;.�-�a-f—r,_ 1� \ - l�."Ar��-Y/-.-.'i'=--L: Grout Inapectlon BY Data Pump Inspection BY Dna ��! OeHruetien Enapectlon By Data Comments: ' ACCOUNTING ONLY: AID# FAC/ PE CODES FEE INFO AMOUNT REMITTED HE (CASH RECEIVED BY DATE 19tl4FIT1SERVICE REQUEST NUNBBt INVOICE L' 0��o�l