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APPLICATION FOR WELLIPUMP PERMIT SAh JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,apt EAST WEBER AVENUE,STOCKTON CA 95201-388 (2091"S 3420 ROM REFUNOA9IE PERMIT EXPIRES I YEAR FROM DATE 13SUEC MemPi6E6 Iw TF4rMtfl &Z.120.IE NE-RY MADE TO THE SAN JOAOUIN CO.—FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW OESCPSSED TIPI6 APPLICATION le LADE IN COMPLIANCE WITH SAN IN COUNTY D 1 OPMENT TITLE CHAPTER B 7 1 1 6 3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALT9 BERVICEe ENVIRONMENTAL HEALTH OMMON r ( /,/TC e.. a LFII JOB ADORESS/OR APNF eJ J /r I. / r .. -I /- F CRY ) PARCEL g2EJAPNl OWNER NAME �/ i/ JJ !r /�J� ADDRESS�///�S �(/ f`. I. Il/ Jr! ONE f COMRAC7oR r i I r J 1 /1/ AOOR[es J{/I'J r r/ ./'r `rA1CF ( PHONE I %1 SUB CONTACTOR 1 .- /l I �/./ ADDRE AS r f ` 7 /[ .+ LICI + PHONE f / TYPE OF WELLMVMP, ❑ NEW W13 Ry..F'S.IONI ELL REPLACEMENT WELL To—a WELL/W^ ] 14— ❑OTHER ❑ INSTALLATION 11 WELL SYSTEM REPAIR /❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL E J 11H—LJ F—Ow, H P DEPTH PUMP SET FT FIRST WATER LEVEL O RYPE OF PVMPI I ❑OUT-OF SERVICE WELL O OEOPwmCAL WELL/ ❑ SOG BORING 8 ��LP--TT I /L DESTRUCTION INTENDED USE TYPE OF WEltCOkJ TwLAC TIDN SPECIFICATIONS A ❑INDUSTRIAL ❑OPEN BOTTOM PIA OE WELL EXCAVATION TNA OF CONDUCTOR CAGING O ❑OOMESTICIPFEVATE ❑GRAVEL PACKARE TOTE OF CABINOMTEEUPVC l."f DIA OF WELL CAIIHO D ❑PUBUCMIONICIPAL ©DRIVEN DEPTH OF OROUT SEAL Y/ 1 SFECIMATION A 0 IRWGATIONPAG ❑OTHER / GROUT SEAL INSTALLED BY GROAT BRAND NAME E j ❑MONITORING ' \� GROUT SEAL PIMPED [IV. ❑N. CONCRETE PEDESTAL BY DRILLER❑Yw ❑NP S APPROX DEPTH T LOM940 CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIOIIWNG METHOD MUD ROTARY AIR ROTARY AUOER CABLE OTHER I HE9[BY CERTIFY THAT R HAVE PREPARED THIN APPLICATION AND THAI O ME W01K"LL BE bGNE M ACCORDANCE WITH IAN JOADINN COVHTY ORo1HANCE4 STATE LAWS AND RIR,Ef AND REGULATIONS OF THE SAN OOAOUIN COUNTY NOW OWNER OR LICENBTD AGENT S SIGNATURE CERTIFIES THE FOLLOWING I CERTIFY THAT IN THE PE/1FOIWANCE OF THE WORK POR NMICH THIS PERMIT 19 IRRUED I SHALL NOT EMPLOY PERSONS SUBJECT TO WORIIMAN S COMPENSATION LAWS OF CALIFORNIA CONTRACTOR■HINNO OR BU"ONTRACTING Po NATURE CERTIFIER THE FOLLOWING 1 CERTIFY THAT IN THE PERFORMANCE OF THE W W FOR WHICH THIS F4RMR M ISeUED 1 SHALL EMPLOY PERSORe BUWECT TO WORWAN 6 COMPIDISATNIN LAWS OF CAUFORM THE APPLICANT T CALL N HOwN S IN ADVANCE FOR ALL REOUIPED INSPUCTIONA AT 12OSI 4Yd 23/ COMA.FT DRAYANO AT LOWEA AREA PPIOVIDEO AA�r,,h�� APPL/ SOLOIST TED. _ J PLOT RAN 0—N Po ,d SIN. 1 1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY t LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED S OUTLINE OF THE PROPERTY OWING DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMS 3 DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED E LOCATION OF WELLS%Vrr"N RADIUS OF ONE HUN4RE0 FIFTY R STRUCTURES INCLUDING COVETED AREAS SUCH AS PAY106 MvEWAYB AND WALKS ON THE PROPEM Y OR ADJOINING PROPERTY I O r _ DOOAA EXT USE ONLY r D. JI ti1J'�/L- G wT v+ a.I P—'V--BY D.I. OwL kIw 1r,tP.rlb.eL 0.L C..nn.�.l I ACCOIAYTlkO ONLY AAI FAC/ CODER FEE INTRO /WOVIrt R�STTET) CN[CR/IC A3k wECOV[9■Y DATE Pe"TPSUTVICS RSOILEAT NUMBM INVOI[E