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APPLICATION FOR WELLIPUMP PERMIT i SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION { PA BOX 388,SO4 EAST WEBER AVENUE.STOCKMN, CA ZMI- 88 • �,i�,—l * .� �� _�', I (2091468-3420 RON•REPUNUARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I1JP�CATTON 18 HF,FIE-SV 1.IAOE TO THE SAN JOAQUI/1 COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE wow DESmgm.THIS APPLICATION 18 MADE IN COMPUANCE WRIT SAN L A0U3l.CGUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OMEMN. JOB ADORESSIOR APNr(2qq !�. �_n.i-- 4�j�,g,* Crr, Brock w PARCEL 81ZE/APNr /5 3—,2 go—A. OWNER'S NAME_..J/ h4 0l ADD .V, 0x PHONE rSID-335—� CONTRACTOR [, .. . - t LIC, PHONE r 70 S y i r ,., ADDRESS p @uB CONTMC'TOR v 1 .0 Y', I(`Y1 ADOREs3 1.�066 ` acs PHONE r�� ! TYPE OF WELLRUMP. NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL r ❑OTHER INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR 13 VAPOR EXTRACTION WELL/LEVEI.. O J ❑N°"�E3 � N.P. DEPTH PUMP 8ET FT. FIRST WATER ! TTYPE QF PUMP) p ❑ OUT-0F-SERVICE wELL IIEOPHY'MCAL WELLr con.somm S8—t 5 p— s {' ❑DESTRUCTIONI I INTENDED USE TYPE OF WE11 CO NSTRlUC71ON SPECIACATIGN6 A ❑ WOUSTRIAL ❑OPEN BDTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO_ D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACX/S ZE TYPE OF CASINGISTEM41VC VIA.OF WELL CASINO - Q © PUBUCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SMCSiCAT10H R J ❑ IMlOAT10NIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E - MONITORING N , GROUT SEAL PUMPED: 13Y— Q Ne CONCRETE PEDESTAL BY DRILLEFI:❑Yw ❑Ne S APPROX.DEPTH 0 —(,o LOCKING CHESTER SOXISTOVE PPE S PROPOSED CONSTRUCTIONIDWLWPG METHOD: MUD ROTARY AIR ROTARY AUGER CA81.E OTHER 1 HM13Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 114 ACCORDANCE WITH SAN JOACUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND J REGULATIONS OF THE SAN JOAQURN COUNTY. HOME OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWING:'t CERTIFY THAT IN THE PEFFORIJIANCE OF THE WORK FOR WHICH 'r THIS PERMIT to ISSUED,I SHALL NOT EMPLOY PEH8ON6 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA-- CONTRACTOR'S MPoNO OR BUS-CONTRACTMO SIGNATURE CE'RTMEB - �THE FOLLOWING: -1 CERTIFY THAT 1N T11E PERFORMANCE OF TILE WORK FOR WHICH TH18 PERMIT 18 I@SUED.I SHALL EMPLOY PERSONS SUBJECT TO WORgNAN•i COMrFJIMTION LAWS OF CAIlFORNIA.- THE APPUCAIVT ST CALL 2R IN ADVANCE FOR ALL IIEGtUIRED 1NS/ECTIONS AT(�/}�tla.12J, COMPLETE DRAWING A7 LOWER A11EA PROV1pED. SlOned X I PLOT RAN I- ID+�is BeMe1 Be.1. 'Ie 1. NAME@ OF STREETS OR ROADS REAIIEST TO OR BOUNDING THE PROPERTY, {_ LOCATION OF HOUSE SEWAGE 018M VAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GFWM DIMENSIONS AND NORTH DIRECTION, v EXPANSION OF SEWAGE DISPO@AL BYSTEMS. 3. DIMENPONIED OUTLINES AND LOCATION OF ALL EXISTIHO AND PROPOSED - S- LOCATION Of WELLS WITHIN RADIUS OF ONE HUMORED FIFTY FT. - STRUCTURES-INCLUOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS-AND WALKS, ON THE PROPERTY OR ADJOINING Pmope Y. ` I Ip ....................:.... : • DEPARTMENT USE ONLY_ L%7 AtPPA*tkm Aeevwtwl @Y One / At weal h»Paetlen @r One vox"hdnecden eY D.I. omim ctlen hwve lion Br P - uJ ACCOUNTING ONLY: AID/ - FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECX/!CASH RECEIVED BY DATE Pa-wI TINERVICE REQUEST NUMBER INVOICE S5 f /0 e I Pub.Heatth Serv.-EfMro.173(3196)