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APPLICATION FOR WELUP1fMP PERMIT (4 � AN JOAGUIN COUNTY PUBLIC HEALTH SERYU ENVIRONMENTAL HEALTH DIVISION P.O. 90X 388.904 EAST WM3M AVENUE, 9TOCK'TON. CA 952p1-W 12091 US-3420 `k NOWNEFONDAILE PERM APPLICATION IS HERE By MAGE 70 THE SAN JOADUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDJOR INSTALL THE WORK DESCRRQEO.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN 70AQIMN COU/TTY DEVELOPMENT TITLE,CHAPTER 8-11{1 S.3 AND THE STANDARDS OF SAN JOAOUMN COUFRY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OA o SA VP nY. l�e�Cr CITYc5 Q w. 1•- ® f4 PAACEL 8IMAPHR al�T X - .C,n4�-� OWNER'S NAME �u�p �e cue \ °� ODORLESS c�3 3 3 u+ v ST PHONEJI o 5 CONTRACTOR,� gr-� 'n� �ar M 512-ZIoB � �R 1`'�� „Adx�Ess 2 3� � ui1�,�+*Ia Llcs� PHONE� 2a -yG 5-697� i CONTRIACTOR_�e N rnNQX L 1V C „_ ADINEsS �3 8 '01 t 1�ce�.,�l�c-1°�LICS 1sNONE.916 369-Ngo/ if OF UMP ❑ NEWWELL ❑ REPLACEMENT WELL ❑ MONRraaING WELL/ ; I' OTHEII ori.► ✓op✓/left s,q..,H�`i�$J I y ❑ INSTALLATIM ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL. ✓1 - 13m.13a,.* H.P. DEPTH PUMP SET_FT. I k RET WATER LEVEL [TYPE of PUMP) 13 F I.f � O 13OUT-OF-SERVICEWELL ❑ GEOPHYSICAL WELL! f y P IIGI sol.BoIYN<l B ❑DESTRUCTION: # d ' IF INT�BW®Y N A _. OF IMEli A/ CONI UCTION-IMS35CATION4N ,q ❑ MAIISTIAAL ❑OPEN BOTTOMDIA.OF WELL EXCAVATION DW OF CONDUCTOR CALM D ❑ DOMESTICJPW VATE ❑GRAVEL PAOUBUE TYPE OF CASMG/STEELIPyc `r h dA.OF WELL CASsiO k D r ❑ PUQUCJMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL k SPECIFICATION R F ❑ ROSOATIONIAG ❑OTHER - GROUT SEAL INWALLED BY :'�{I �h GROUT BRAND NAME F ❑ MDNTrommJ ORDUT SEAL PUMPED: ❑v« ❑Nn f# " CONCRETE PEDESTAL By DwLLER:❑Y« ❑Na S APPPXNx.DErTN ?�7 - LOCKMG CHESTER BOX/STOVE RPE s PROPOSED CONSTRUD7gNION M0 METHOD: MUD ROTARY AML ROTARY AUOER + If CABLE n OTHER y ''y � r-,1�b1 Ay rwer�� .�o t rr�i S! n t n r)4b .4r L,4 l,Fra m P `k OC b c b l IC 504 a�Q L HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAQWN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOI/M COUNTY. HOME OWNER OR LICENSED AGENT'S SKLNATURE CER MS THE FOLLOWMOlI I CERTIFY THAT IN THE PERFORMANCE OF THE wows FOR WHICH ' THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO wamiKAwa COMPENSATION LAWS OF cALIFOAMA.' CONTRACTOR'S HNRIM OR 8116 COPITAACTIRIG SIGNATURE CERTiF1E6 ; THE FOLLOWMG: '1 COMFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH TIME P9SWR IS ISSUM.1SHALL EINPLOY PERSONStWB.RECT TO WORIOWAN'S COMPERSATION LAWS OF � CAUFORNIA.' THE APPLICANT MUST CALL 24 HOLM N ADVANCE FOR ALL IIEOUIR®PMPSCTHOIRS AT MOM)4M4MZ*. col. TE DRAVNNO AT LOWER AREA PRIDVIDED. _I Slprnd X I � TIMr r� `r I Drtr PLOT PIAN IDrtaw to Saolol Satyr-, to Le,'I I. NAMES OF STREETS OR ROADS NEA ESr TO OR BOUNDINIO THE PROPERTY. 4. LOCATION OF HOUSE WWAOE DISPOSAL SYSTEM OR PROPOSED x. OUTLINE OF THE PROPERTY,ONMNL DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 1 7. DNJIEN&pNEp OUTLINES AND LOCATION OF ALL EXISTING AND PRO SED ,h S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.' i STRUCTURES.INCLUDING COVERED MEAS SUCH AS PATIOS,onvEWAY6,AND WALKS. ON THE RLOPERTY OR ADJOMMG PROPERTY. -- --- -. .....:........ .. ..... k ....... MAP DN BACK............ ........................... :.. .. ............ i ..................... i ....... .......... ............. ...................... I DEPARTMENT USE ONLY Arrrdl«tbrt A—opted By. Date Are* Gmn lim mft SY Ortr Pump Irnorotlon by Dat@ Dmrtnatbn Inrpretlan By n[ 'I Drtr 9 Ce.nerrrner: !� I AccouNTtNG ONLY: ARD, FACT �I - PE CODES FEE DEO AMOUNT REWRTEO CHECINJCASH RECEIVED MY P IV ATNSEMCE REQUEST NUMBER INVOICE '