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r APPLICATION FOR WELLIPUMP PERMIT a V SAN JOAQUIN COUNTY PUBLIC HEALTH SER'- S - ENVIRONMENTAL HEALTH DIVISION 0002 �.O OX 988,304 EAST WEBER AVENUE, ST'OCICTON, CA'85201 X88 �—,0 !µ `�� -' (209) 468.3420 ► NON-REFUNDADtf PERMITX IR S I YEAR FROM DATE ISSyED APPLICATION 18 HERE BY MADE TO THE BAN ICeNnpirle In Tripketi) r. JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED;THIS APPLICATION IS MADE IN C0611'L.IANCE WITH SAN IOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER$,1 6.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDAEBBJO r�-t3._1�1r�! F i. i+��/+r 6 3 CITY r + PARCEL SIZE/ 1AP!!I OWNER'S NAM I j ADORES8 CONTRACTOR_- I)�i 4 f 1 �!l'. �►1 C� � PRONE r i �^'•�� ADORES s .L l LICK ;d 9!G PHONE# 8Va CONTRACTOR I, LICr I�. .. ADORNEB$ ' ., ---PHONE r < Ids I=OF WM PVMM ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL R ❑ INSTALLATION ❑ WELL SYSTEM REPAIR — ❑ OTHER_ .. ❑ CR088-CONNECT REPAIR ❑ VAPOR EXTRACTKIN WELL r J —�� 13 Now❑Repel, H.P.� Y DEPTH PUMP BET (TYPE OF PUMP) FT FIRST WATER LEVEL i{ i ❑ OUT•OF•BERVICE WELL ❑ OEOpHY81CAL WELL# I ' ❑ SOIL BORING • I1� •� DESTAUCTION- TYPE O W ONi R O Bp IFl IONS �h ❑ INDUSTRIAL {' A OPEN BOTTOM DIA.OF WELL EXCAVATION �I GIA.OF CONDUCTOR CASING O ❑ DOMESTIC/PRIVATE L�GRAVEL PACK/SIZE TYPE OF CASINGISTEELJPYC �C� DIA.OF WELL CASINO D ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL t SPECIFICATION �p✓-f�/G, �f �O I� ❑ IRPoOATgWIAO ❑OTHER r -- R GROUT SEAL INSTALLED BY Lf GROUT BRAND NAME E MMONI70PoNG GROUT SEAL PUMPED. CRY.. 0 N CONCRETE PEDESTAL BY DRILLER ®Ne g } a t Y Q Yr AppgOX.DEPTH_.. .. LOCKING CHESTER 1IOX18TOVE PIPE L, T. a I S PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR VOTARY AUGER // CABLE "' OTHEFj i I HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SMI JOADVII COUNTY ORDINANCES,STATE LAWS,AND RULER AND REGULATIONS OF THE SAN JOAQUIN COUNTY.'HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TWO PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONB SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORHIA• CONTRACTOR!S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOYIFiO: 'I CERTIFY, HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORIONAN'i COMPENSATION LAWS OF CALIFORNIA-*,THE C MUST C URS IN ADVANCE FOR ALL IMOUNM INiMUOINS AAT��1120'0114*84423. COMPLETE DRAWING AT LOWER AREA PROVIDED,; SiBnedX / TW��32`,�:.:?�'1 ---�: . Date _00 t ISI ' PLOT FLAN IDrary is 8oeiel So}[r •to I' jjo' 1. NAME$OF9PROPERTY, OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR pROp08E02. OUTLINE OF GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. I� L� 3: DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED f. LOCATION OF WELLS WITHIN RADIUS S T ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,MIO WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, 'r ..............i.... i......i......i.... .. .. .. .. .. .. _ :.....:..............::......E.....5.......E-.. .. SrRE CT I ... ry......:... .:.......:.............,:.......;..,.......................... r .— yy�� ............................�.....-......-.,....... -.:..........:....: .. .. .. :. .. .. .. .. .. AL [: h. T : .-l. I ....................... . ......:.............:..............:.......:......:...... ......`....... .........,;............;... ET..11YIi0L SI�LE..DRUG...CO..... ... .. YA�4. :.. ..> :.............:....... i......'.........-..':.......... .. .. .;. : . .... .. .. ....3.. ..... ....ti,.y... .. ....YYoe i'o1�+�r�4lr:sT... .. .. .. .. .. .. q ... 1 op : . ..:..........:......:................................ .... ........ �,' .. .......... :. . 1 .. ........... i YS=..—. .'•-rN.s:;�:'�ii:��c''i�,."�'"4':aF:�.,��Yr:y1r`:Y i:ti�:"(:.^-h->.:-. :��-- - , .4_:� -. �_ � �'^'Ji..�y'+.W-:T/�.'�f:SL-y�:4wF �•di�IR:•9.R:�1�:'Ylfl,All'F:'9��^•tYY� YI��:' ..::......:.. .�:.. ..MNL:... s ..i... ...._ .. ......� ;MWS,.�... J. : 11. :......:......:......:......a......:......i......:......:..t.,..:.... .. ....... .. .. ......,. ., .. .. .. .. .. .. .. .. .r�.. i = I 'E i i� DEPARTMENT USE ONLY �J }� Appllwtlon Aerated BY Do. l 0 l� Area, ' Grout Irrpecdon By Drtr t P lrupertirn By. Dote DooWntion IrrpoOlon By i Oete Cornmwttt¢ ACCOUNTING ONLY: AIDr FAC# , FE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE P9W11TIOUMCE REQUEST NLWSER INVOICE Sp00 1 W7 a3 i, I f I'