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' :AP.P.LICATION FOR WELLIPUMP PERMIT AN.IOAIIUIN COUNTY PUBLIC HEALTH SERV ENVIRONMENTAL HEALTH DIVISION ' �t - P,O. BOX 388. 304 EAST WEBER AVENUE:, S7"OCK't m CA 5'26t-s88 y, :. v. 1209) 468.3420 - : A�sirf. NON-REFUNDABLE PERUR �LJ ' APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,THIS JOAQUIN COUNTY APPLICATION IS MADE IN COMPLIANCE WITH SAN DEVELOPMENT TITLE,CHAPTER 8-i 11 .3 AND THE STANDA S OF SAN QUIN CO PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. tfJ08 ADpREBS/OR APN# CRY PARCEL BRElAPNs OWNER'S NAME - - -. ADDRESS PHONE# p CONTRACTOR 1 'L-rl—l��e•�C(.�-+-1 - ADDRESS E1 LIC# RiOHE a �,, J7 SUB CONTRACTOR`S�4 IA! ', ADDRESS �# ( PHONE# ga6rr'r.k 1: (Ift Ciu: r/ -- ��•u�.oaaaa�r_mnaaaaaa TYPE OF WELUPUMP• NEW WELL ❑ REPLACEMENT WELLNITORING WELL# . 1: ❑ OTHER - INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR iI' 0 VAPOR EXTRACTION WELL., ,) ❑Naw 0 Repair H.P. DEPTH PUMP SET FT. (TYPE OF PUMP) FIRST WATER LEVEL O ❑ OUT-orSERVICE WELL 13 GEOPHYSICAL WELL# ❑ BOIL BORING. � ❑DESTRUCTION: INTENDED URE TYPE OF WELL CONSTRUCTION SPECIFICATIONt '! - A ❑ INDUSTRIAL 0 OPEN BOTTOM d1A.OF WELL EXCAVATION - DIA.OF CONOUCTOR CASINO ` ' p 13 DOMESTIC/PRIVATE RAVEL PACKS TYPE OF CASINOIVTEOM% DIA,OF WELL CASINO p ❑ RIBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION. 'R ❑ amaATKGNIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ONROWNG - >> GROUT REAL PUMPED; ❑Yw ❑Ne C CRETE BY DRILLER:❑Yr ❑Ne ` 5 IIAPPROX.DEPTH . LACKING CHESTER BOXISTOVE �L PROPOSED CONSTRUCTIONAMLLINO METHOD: MUD ROTARY `AIR ROTARY AUGER CABLE OTHER - - 1 HEREBY CERTIFY THAT 1 HAVE PREPARED T14I8 APPIJCATION ANO THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS;AND RULES AND � REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S StONATURE CERTIFIES THE FOLLOWING;'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAW8 OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERT[FItS THE FDLL NO: •i GERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,!SHALL EMPLOY PERSON8.8UBJECT TO WONIGIIFAN' COM SATION LAWS OF CALIT-GRN T Mllt7 CALL Z4 NOURS IN ADVANCE_ FOh ALL REQIMIm TIONS AT(2MI Apa42]. COMPLETE ORAWIN(G AT LOWER A �, O! h ' PLOT PLAN 8>'raw to BOeNI Bash r'to .. 1. NAMES OF eTREET'e RR ROADS NEAREST TO OR BOUNgINO THE PROPERTY. _ 4. LOCATION OF NOVSE SEWAGE DIBPDBAL.SYSTEM OR PROPOSED : 2. OUTLINE OF THE PROPERTY,OIVtNQ DFMENBIONS AND NORTH pIRECTION. ^ EXPANSION qF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED '. S. LOCATION OF WELL8 WITHIN RADIUS OF ONE HUNDRED FIFTY FT.- STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANDS. ON THE PROPERTY OR ADJOINING PROPERTY. ^- . . _. -'jeoNgAcK. .. ......... ........... ....... ........... MAP ry _. DEPARTMENT USE ONLY Application Accepted By ' Date 7 Or"Impectlen BY - pate- 'k r Puny IropacGert By Date i t)aatruethn Inepacthn Data w ll COramente: ACCOUNTING ONLY: t AID# FAC# PE CODES FEE INFO AMOUNT R13YIITTE'D CHECK#/CASH RECEIVED BY _ DATE P.IiMITISHWICE REQUEST NUNINER INVOICE 5d k e - w