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APPLICATION F08 WE'LLIPuMP PERMIT tSAN JaAaUrN cauNTY PueLIC HEALTH SERI PI gOX ENVIRONMENTAL HEALTH DIVISION -"/ 988, 304 EAST WEBER AVENUE S CA (209) 408.3420N' 9520i�388 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED APPLICATION 18 HERE By MADE TO THE SAN JOAOUIN COUNTY FOR A PE JOAQUIN COUNTY {1.4" b In TrlpRe�ts) DEVELOPMENT TITLE,CHAPTER 9.11 5 3 PERMIT TO CONSTRUCT AQUIN INSTALL THE WO S5� r+ AND THE STANDARDS TO C OF SAN T JOAQUIN COV AK DESCRIBED.THIS APPLICATION JOB ADDRESSOR APN# f'F t E NTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. / COMPLIANCE WITH SAN OWNER'S NAME l.1 0 S� CITY �.ypQ '/ �r� `_ • 1 jj�.DOT SJ PARCEL SII l COMTRACTO� DRESS 1-�� yy �� w1V� fliF drLL" tVIIII . ADDRESS L PHONE OUR CONTRACTOR�� ItY+n yet, � �x �Qb q PHONE/ZL^�- �O1J S - ADDRESS '/O LICs±off `1J PHONE 1Ug_Y� TYPE OF WELLIPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL x ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑New❑Repelr H.P. DEPTH PUMP SET FT. FIRST ATER LEVEL 0 (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL f BOIL BORING g ❑DESTRUCTION: a'e iee� ICATIn.u�rr_ WENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q 0 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGIBTEELIPVC DIA.OF WELL CASING O ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑No CONCRETE PEDESTAL BY DRILLER:❑Yaa ❑Ne S APPROX.DEPTH LOCKING CHESTER SOXMTOVE PIPE S PROPOSED CONSTRUCTIONMM IND METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOA43UIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORT(FOR WHICH THI8 PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE AP�7�1� MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPPECTIO A 144111-24.22. ,fOMPLETE WING AT LOWER AREA PROVIDED. Slpned X \ J\ Title • �'� PLOT PLAN(Drew to Scala)Seale 'to y S. NAMES OF STREETS O ADS N AREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPS 0 DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING 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. DEPARTMENT USE ONLY f r� Application Accepted By Date I - T Arae Great Inspection By Date Pump Inspection By Date . Destruction Impaction By Date Comments: ACCOUNTING ONLY: AID# FACS FE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PEWTISERVICE REQUEST NISJIBBt INVOICE 35b 7w ��' DL 0 8 O