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APPLICATION FOR WELLIPUMP PERMIT SAN JUAUUINCOUNTY PUBLIC NMENTA! HEALTH QIYISHON RVIC ENVIRONMENTAL .- 304 EAST WEBER AVENUE.sj4oc t4,CA 95201�8e p,0.BOX 988. 1209) 468.3420 NON-REFUNDABLE PERMIT EER,iRES I a FROM BATE ISSUE4! SAN (Camp SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENViFlONMEI'ITAL HEALTH DIVISION. TO THE SAN JOAQUIN COUNTY FOR A PERMIT 70 COONF TRUCT AHDlOR INSTALL THE WORK Df SCRIBED.T1119 APPLICATION 15 MADE 1N COMPLIANCE WITH APKICATIOH IB HERE BY MADE �/�- PAR EL BIZFJAPNR i JOAQUIN COUNTY DEVELOPMENT TrtLE.CHAPTER 3 AND THE STANDARDS CITY r/at' l+ W/.� gpd`r'r l JOB ADDRES9IOR APNI L PHONE# Z ADDRESS J 44 4 y`PH �� OWNER'S NAME �Zr UCR PHONE �•l s ADDRE89 . v� �27G { CONTR!•.CTOR /�. r - y( ut# 9' PHONE , ADDRESS 3Z -f 7'2 SUB CONTRACTOR✓✓ Hf tlNrTORINO WELL R�" ❑ OTHER TYPE OFA ❑ NEW WELL ❑ REPLACEMENT WELL J ❑ INSTALLATION ❑ WELL SYSTEM REPAIR CR089-CONNECT REPAIR [IVAPOR EXTRACTION WELL! O .❑New❑Ftrpelr s H.P, DEPTH PUMP SET FT. FIRST WATER LEVEL HYPE OF PUMP) ❑ cuT-orSERVICE WELL ❑ OEOPHYSICAL WELL# ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑-INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL➢ACK/812E TYPE OF CASMOISTEELIPVCS yo Pvl GIA.OF WELL CASING // O ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPT14 OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E MONITOAINO GROUT SEAL PUMPED: ❑Yas ❑No CONCRETE PEDESTAL BY DRILLER:❑Yrs ❑No S APPROX.OTFTH� I D LOCXINO CHESTER BOXMTOVE PIPE $ PROPOSED CONSTRUCTIONIDRI LUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE7EBY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,BTATE LAWS,AND RULES AN rtFOULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE Or THE WORK FOR WHICH THIS PERMIT IS 1681JED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENRATION LAWS OF CALIFORNIA.' CONTRACTOR'S HINNO OR SUB-CONTRACTING SIGNATURE CERTiF1E6 THE FOLLO%MNO: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMrT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIGNAWS COMPENSATION LAWS OF CALIFORN INE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REIIP REQUIRED INECTIONS AT(2466-S423.1 4ees%a, COMPLETE DRAWING AT LOWER AREA PROVIDED. k-41 43Slpned% Tllle {�3+ ,�/ /�//1 r -- - r� et PLOT PLAN(Drew to Bode)Sade 'to t. NAMES OF STREETS OR ROADS NEAREBT TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY,GIVING DIMENSIONS AHD NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 8. DIMENSIONED 01fTUNF.9 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, STRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY, r o- DEPARTMENT USE ONLY T Appllaetlen Accepted By p l' Geta Q Arae 1/r � , Grout Insbeallon BY bile Pump Inspemten By Dote Oedrncllen Mopecllon By Dole ACCOUNTING ONLY: AID# FAC,/ PE CODES FEE INFO AMOUNT REMITTED CHEe CASH gECEIVED BY b PERMITISERVICE REQUEST NUMBER INVOICE Pub.Health Serv,-EnYirO.173(3/36) - a