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EI APPLICATION,FOR WELL -__- i� `►%SAN JOAUIN COUNTY U$LICPHEALTNRMIT P•O. BOX 384 ,304 `304 PAST ENVIRONMENTAL HEALTH DIVISIOIyER1„ycS I WEB EA AVENUEI STOeXrON . (209).488.3420 ► CA 9S20i,%q APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COV NON-REFUNDABLE PERMIT EXPIRES JOAGUIN COUNTY fColn YEAR FROM DA E.ISSIOR f� DEVELOPMENT TITLE CFIApTER 9-1113.3 Y FOR A p G In Trlpjkatal PERMIT TO CONSTRUCT A.NojoR INS I JOB ADORESBION A # A D THE STANDARDS OF BAN JOAQU N cot) L THE DE.8d- THI WORK e OWNE ` PUBLRC NEALTFj SERVICES EN ATI A N R B NAME Q �I ITY HRONMEM DIVISION,EDWITH SAN AL HEALTH f CONTRACTOR ADDRESS S(^� BUS CONTRACTOR J K.S ik � ADDRESS VISIONM Lit e TYPE 0 ADDRESS NE r �� MP' ❑ NEW IyELL ❑ REPLACEMENT WELL PHONE 0— New INSTALLATION I' ❑WELL SYSTEM REPAIR 11� MONITORING WELL 13 CROSB.CONNECT REPAIR OTHER f [TYPE OF PUMPI n J4r y.14.P.��y r1 f J may= i DEPTH PUMP SET��FT ❑ VAPOR EXTRACTION WELL I�� J 1 ❑ OUT-OF-BERVICE WELL FIRST WATER LEVEL []DESTRUCTION: ❑ GEOPHYSICAL WELL# � d ❑ soli BORING B , INT DED VSE } _YPE�F yy�t d IN USTRIAL CONSTRUCTION aPECIFlCA IONS I OPEN BOTTOM DIA.OF WELL EXCAVATION DOMEBTICIpryIVATE •` DIA.OF CONDUCTOR CABINO - A EE �GRAVEL PACK{82E D .I f.,❑Pusuc MUNICIPAL —�— TYPE OF CABIN0/6TEEL/PVC ❑DRIVEN � DIA.OF WELL CASING - DEPTH OF OROUr SEAL D ❑ IRRIGATKINIAG ❑OTHER SPECIFICATION it GROUT BEAL INSTALLED BV R !S❑ MONITORING � GROUT BRAND NAME � !! ! GROUT SEAL PUMPED: ❑Y« ❑Ne APPROX.DEPT" .I CONCRETE PEDESTAL BY DRILLER:O Yos ❑Ne �, IifYPROPOSEA CONSTRUCTIONIDRILUNO(METHOD:`MUD ROTARY LOCKING CHESTER BOKIBIOVE PIPE [� AIR ROTARY AUGER _CABLE I OTHER i HE 4EBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUEN COUNTY ORDINANCES,STATE LAws,AND RULES AN REGULATIONS OF THE CAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WNfCGT THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'8 HIRING OR BUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOMNO: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAws CAUFORNIA.' APPUCA T MUST C Z�'HOUR$IN ADVANCE FOR ALL REOUIRED INS TIONS AT 13081440 !- COMPLETE DRAWING AT LOWER AREA PROVIDED. .Slpntl X Title beg2_'Oa EI �� PLOT PLAN 10row to Boole)Sgolo to 1. NAMES OF STREETS OR'ROA68 NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED, �. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED G. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.. I STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. I! :Ali r ....' Iy - ......,." ....... ..................',... / .;..., .. .. .. .. :.-.,.,-. -.-... ................... ..... .. ., ..,.. ., .. .. .. .., Eg ... ...,...... i Wim} .,.. .. .. p ... .. .. i I� 3 P .. .... i EMIL T: 5f FiVtC•E l ISI tir PUB IG H ...ENVEF��? E�4..A�,.H�PL7h-1.i�t\� DEPARTMENT USE ONLY - .'lApplk:atlen Accepted By Date Ara 71 EIGIotA Irnpeetlon By Date Pump Inspection 8Y r w Date L r; 177 [,'Deetr��IrtIJi4 irnpeati/Io��n By rr�� 1 � Date Comeh�lts:7-6c 6 d j qjM ; r) •i ACCOUNTING ON AIDR If FACT E .E E PE CODES FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED BY DATE 1101h11TISERVICE REQUEST NLIMBEIR INVOICE p 0 031 �i i