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PPLICATION FOR WELL/PUMP PERM D SAk v0AOUIN COUNTY PUBLIC HEALTH SE CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER 2QV�E9N�-3 T2U CKTON, CA 95202 ORIGINAL 110R-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED IComplata In TripReatel APPLICATION 19 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 WrTlf SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SER EB.ENVIRONMENTAL HEALTH DIVISION. 111 1 c {�A _ c' JOB ADDRESSOR AAPN# ,ZZ 1 ( '`^J i L(/,1 S'qk I YY/-1 4 CITY I C�r �� 1 PARCEL SIZE/APNP I _/��—� OWNER'S NAMEG�-t�>N� C l-� '-'�IJT ADDRESS_��JL�/I �'I t•/�1 L�CJ� } PI10NE R (O`2411 C RACTOR .7 n {- l�J'�-y / ADDRE88`�(-)57 WIIL i/�I�'N/��}' LSCI ' 6 PHONE I R C OA Ttl� rp fl'1 (-1 i L� GI L�r-W-1� ADDRESS PA CJS "LICK PHONE I 6lrt> I TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR088-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ❑New❑Repel, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP1 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL f SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN 80TTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING G 0 ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELMVC DIA.OF WELL CASINO �1 O ❑ PVBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 5 SPECIFICATION R ❑ IRRIGATION/AO ❑OTHER GROUT SEAL MSTALLEDSY-1--jZ.1 a t,io-N GROUT BRAND NAME E rg P–MOWTORING 1 GROUT SEAL PUMPED: I -Y. [IN. CONCRETE PEDESTAL BY DRILLER:❑Y« CIN. S l APPROX.DEPTHLOCKING CHESTER BOXMTOVE PIPE LC 6_K 1 L,G S� PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER_ L CABLE OTHER 1 HEVEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REOULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SU!"ONTRACTM6 SIGNATURE CERTIFIES THE FOLLOWING: "I CERT THAT N THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT 18$Sam,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' A AN MV CALL OURS IN ADVANCE FOR ALL REOUIREO INSPECTIONS AT 1200)ASS-3/427. COMPLETE DRAWING AT LOWER AREA PRO OED. . Sipned X. Title i Ui L ��(�1 tV��(Z Doi d I FO PLOT PLAN(IN—to Soelel Basle 'to l' 1. NAMES OF STREETS OR ROADS NEAREST TO OR B THE PROPERTY, t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE Of THE PROPERTY,OrVMG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OVTUNF.S AND LOCATION Of ALL EXMTWM AND PROPOSED S. 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. q DEPARTMENT USE ONLY /n9 AppRoetlen Aooepted by ` 'F� r / M« G,wA%.poatlon By Dets C impectlon By Det. Doetn flen Inepectlon Sy /{� le — Commer.te: / / tl 2 ACCOUNTING ONLY: AID/ FACS PE CODES F INFO AMOUNT REMITTED CHECKI CASH REC sY DAT PERMITISERVICE REOUEST NUMBER INVOICE 2z)23 Pub Health Serv.-Enviro. 173(1/97)