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i <br /> ( APPLICATION FOR WELD UMP PERMIT �JT r <br /> _: Df <br /> SAN�JO.AQUIN�OC�N'TY PUBLIC WEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, ST CKTON, CA 95202 FILE <br /> (209) 468-342 COPY <br /> NUN-REFUNDABLE PERMIT EXPIRES 1 Y A FROM DATE ISSUED <br /> (Complete M TFIpRe t/1 <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOLSN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR! GTALL THE WORK DESCRIBED.T1118 APPLICATION IS MADE IN COMPLIANCE WRII SAN <br /> JOAOUIN COUNTY DEVELOPMENT TrTLE,CHAPTER 9.1 115.3 AND THE STANDARDS OF BAN JOAOUIN C UNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, I <br /> JOB ADDRESSOR APNI 1034m 4-n— 4 CfTY I r�G P RCEL 8I�E/APNR <br /> OWNER'S NAME CE4.. ADORE 198 -. v' <br /> PHONE c <br /> CONTRACTOR '11 a Z <br /> ADDRESS 6 Sf..O LIC! (7. Zy PHONE/•1iQ-•LCEj'�Q�S <br /> RUB CONTRACTOR ADDRESS uce PHONE F <br /> TYPE OF WELUPUMP: CI NEW WELL ❑ REPLACEMENT WELL ❑ MONRORING wEi L R ❑ OTHER <br /> ❑ INSTALLATION © WELL SYSTEM REPAIR © CPASB-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL N 1 <br /> ❑New©R.p.l� H.P. DEPTH PUMP SET Fr, FIRST WATER LEVEL O <br /> n YPE Of PUMP) <br /> ❑ CVT—OF-SERVICE WELL ❑ GEOPHYSICAL WELL IF OIL BORING 9 <br /> ❑DESTRUCTIONt <br /> INTENDED USE TYPE OF WELL CONiTRLIC PION/PECIFIIIATIong A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA-OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑ OOMESTICIpRIVATE ❑GRAVEL PACKMfZE TYPE Of CASING/STEELPVC DIA,OF WELL CASINO O <br /> ❑ PUI LICNMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION H <br /> ❑ IRRIOATKOWAG ❑OTHER GROUT SEAL INSTALLED BY OROUT BRAND NAME E - <br /> 9'�ONRORINO GROUT SEAL PUMPED: ❑Yr No CONCRETE PEDESTAL SY DRILLER;❑Yee CIN* s - <br /> APPROX.DEPTH LOCKING CHESTER BO KISTOVIE PINE S <br /> PROPOSED CONSTHUCTIONIDRILLIRO METHOD; MUD ROTARY AIR ROTARYAUGER--- CABLE OTHER— it o' <br /> 1 HE9E8Y CERTIFY THAT 1•NAVE PREPARED THIS APPLICATION AND THAT THE WOl WILL BE DOME M ACC "DANCE W"SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULER AND <br /> REGULATIONS OF THE SAH JOAOUIN COUNTY, HOME OWNER OR LICENSED Al SIGNATURE CERTIFIE I THE FOLLOWINO!'I CERFiFY THAT IN THE PEWORMANCE Of THE WORK FOR WHICH <br /> TRIO PERMIT IS ISSUED,1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCOHTMCTM S1ONATURE CERTIFIES <br /> THE FOLLO CERTIFY THAT IN 711E PERFORMANCE OF THE WORK FOR WHICH THIS PERMrT 18 I$ Mn.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'/COMP4NSATION LAWS OF <br /> CALIFO A ANT MV/T CA Z1 HOURS N ADVANCE FOR AU <br /> EOUIRED INSPECTION/ATI I�ee->H OMPLETE ORA AT LOWER AREA PROM fD. (�[� <br /> e� ,rOCATitle f ` r <br /> D.K. <br /> vv Ir Ej <br /> PLOT PLAN IO,aw to Saal.l e.a[. to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNa1NO THE PnDKRTY, /. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OA P"OPO BED <br /> 2. OUTLINE OF THE PROPERTY,OIVMNO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL eYSTEMB. . <br /> 2. DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING AND PROPOSED 1. LOCATION OF WELLS VVITWN RAO{VS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,IR:LUOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. OH THE PROPERTY OR ADJOWMp PRDFv". <br /> P10, <br /> bWARTMENT USE ONLY <br /> to M <br /> H � <br /> Apple„tan Aaeapted Br �/`/ ~ / / <br /> ao <br /> u,”r vpeeflen B* YZ Data Pump In.pec,ton BY Date <br /> 0-Irtiellen tmpaetlon BY a.ta <br /> co--"., ,� 2— <br /> ACCOUNTING ONLY; AID/ FACT <br /> PE CODER FEE INFO AMOUNT REMITTED CHECKR/CARH RECEIVED BY DATE PERMITIOERVICE REOUEBT NUMBER INVOICE <br /> -04*86 <br />€ Pub `.Mh SGrv.-Enviro.173(1/97) <br /> f <br />