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APPLICATION FOR WELLJPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES "-� ENVIRONMENTAL HEALTH DIVISION 304 ENU AC ON, CA 95202 (209) 468-3420 (V -{-�A/ NO •R FUNDAIIE PERMIT EVIRES 1 YEAR FROM QATE ISSUED (GRhMtf k TFfVtk[tfl APPL TION IS )ERE NY MAOE TO INE SAN JOAMP LINTY FOR A Pf3MFT TO CONSTRUCT ANOMR INSTALL THE W01K DESCRIBED.TIRg APPLICATION Ie MADE IN CO►AMIANNCE PURIM SAN JOAOWH COUNTY DEVELOPMENT TTTU.CHAPTER 9-1116.3 AND THE orTANDAres OF SAN JOAGUIN COUNTY PRISUC HEALTH SERVICES,ENNRONMENTAL HEALTH DMelow. JOB ADOM ESSIOR APNF 9/7 CITY[,(,yn[ PARCEL SIZFJAPNF OWR1[R'S NAM[ / •� /1 //+� �]/� ADORE88 �/V C IV t / �•7 PHONE CONTRACTOR L v r H �/J �/ ��'�•� AODMff J- dS'r�1/, ' �PNONE RUS CONTRACTOR AOORES$--dV5tlC1 MfONE r TYPE OF WFLL/RIMP: ❑ NEW WELL ❑ REPULCEMENT WELL ❑ MONITORING WILL I ❑ OTHER ❑ INSTALLATION © WELL SYSTEM REPAIR ❑ CROSS-CONWCT REPAIR ❑ VAPOII EXTRACTION WELL I J ❑H.w❑RrpMr N.P. DEPTH PLUMP SETR. �,r( FJSff 9, 7-' O MY OF , II ❑ OVT-OF-SERVICE LL ❑ GEOPHYSICAL%IM I �❑, @OIL BOLTING e &a IT roPr INIDODEQ USE f YP■OP WELL, CONSTRUCTION*KVjF1CAtwHa A Cl NDUBTPWAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION VIA.OF CONDUCTOR CASINO O ❑ DOMESTICSWVATE ❑GRAVEL PACKYew TYPE OF CASiNOre TEEtUPVC DIA.OF WELL CASINO D ❑ PUK)CINJLNICWAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ DGSOATIONIAG ❑OTHER OROtn SEAL INSTALLED BY GROUT DRAM NAME E ❑ MOMTORING OROUT SEAL PUMPED: [3Y. ❑N. CONCRETE P'EDEBTAL SY GRILLER:❑Y.. [IN. S APPROX.0E1TH LOCKMO CHESTER 9OX/9TOVE PIPE S PROPOSED CONETTIUCT10NjVML1f0 METHOD: MVO ROTARY AMI ROTARY AUGER CAIU OTHER 1 HERESY CERTIFY THAT I IIAVE PREPAREIO THIO APPLICATION AND THAT THE WOPK WILL SE DONE IN ACCORDANCE WITH SAN JOAOUN COUNTY OROIINANCES.STATE LAWS,AND RULES AND rWWAATIONS OF THE SAN JOAOLRN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTWMS THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH TMS PERIATT Is ISSUED,1 SHALL NOT Ir"MOY PEIIfON1 KRUFCT TO WOOKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOPt•$HIRING OR$U6CONIRACTIN01 SIGNATURE CERTIFIES THE FOLLOWING *I CERTIFY THAT M TIN PIEIPQFIhIANCE OF THE WOM FOR WHICH TWO PERMIT IS HISVED,1 SHALL EMPLOY rgRSONS InPOACT TO NORIOAAN'S COMFpSATTON LAWS OF CALJFORSW AP1UCAN MUS2214 HOURS IR AV;Vr FOR ALL R[OtNtm N• T AREAS!!, COMPLETE DRAWING AT LOWER AREA PRIG Eb. �� i if rw,d X Th1. - - - - -. O.t. - PLOT RAR RaµI.S•.hl Baal-_•t. I. NAUtO of fTMET$OR ROAD$NEAREST TO OR SOUNDING THE PROPERTY. <. LOCATION OF HOUSE SEWAGE DISPOSAL fYSTEM OR PROPOSED 1. OUTLINE OF THE PROPIRTY,GRIM DIMENSION*AND NOWN DWCTION. EXPA WON of OEWAOE DISPOSAL SYSTEMS. J. OIMENSIOWD OUTt1NF9 AND LOCATION OF ALL EXISTING AID PRIOPOSED $, LOCATION OF WELL$WOT IN RADIUS OF ONE"LlMORED FIFTY R. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,OmvFWAY/r AND WALK$. ON THE PROPEETTY OR ADJOINING PROPERTY. f .. .. ./.. ... i....... ..... .. ...... , .. .. ' ..t. .. ........ ...0.. ........... .. .. ..i.... .f•. .. .........• ...�. .4.. .r.n......:.. .......:... ........... .. .. . ((yy-... • PAYM NT PECIF _.. . � APR g �OAC'UIN COUNTY pUBUC HEALTH SEAVIGES , ENVIFK}NMFNTAt,HFAf.TH-DlVj5KN'N ENT w[ONLY � L4b AP•M•tlw+Ae.w,.e Sr 0... Nr Eli 0.4 Mrp e•n by 0.4. P—p wap.•Il—Sy 0•t• Dar nKll.n IrrP.olbn$r Data, -7 r ACCOUNTING ONLY: AMN FACT PE CODES FEE Piro ANIOVNT RIMOTTE9 IIEC /CASH RECBVED$Y OAT* FV"TUSRRVIC[REQUEST NLgMO1 INVOICE 6 Y4 �t Pub Health Serv.-Enviro. 173(1197)