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<br /> "'►��^--"f 4 �'. PLICATION FOR WELL/PUMP PERMIT ' r dam"
<br /> SAN JUAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION T, , ti �'Is' �►`'*
<br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95?
<br />+ (209) 468-3420 '" / f,•
<br /> 00111-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> (Compo(e In TrIpReNo) t _
<br /> AN'/'I.K:AT K)N 18 HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.Tills APPLICATION 19 MADE W COMPLIANCE Mill SAN, ,r,•'
<br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND T E STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HTALTH DMSIO t;
<br /> ADIf
<br /> JOS ADOREBS/Of�`AfN/ �1Q CITY /PARCEL SIZE/APN#
<br /> OWNER'S NAME ADORE 88� �7 fCICWT�I1 I,I � ` - PHONE
<br /> CONTRALTO '`� ej_�! I ✓67-3/41
<br /> AODIIEeB P(1�JBx IV3 LIC/AMD
<br /> PHONE l
<br /> SVD CONTRACTOR ADDRESS I , LIC/ 4 PLANE/ j
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<br /> TxP-jOPYVELML_PI ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORINO WELL/ L� OTHE
<br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROee-CONNECT REP , { rt_,J; VAPDA T /] ' WILL T �73-7 t/
<br /> ❑NPAP H.P. DEPTH PUMP SET FT.
<br /> (TYPE OF MPI
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<br /> OLFT-OFSERVICE WELL ❑ GEOPHYSICAL WELL/ Y ❑ 600.BORING
<br /> ._.•-q pF��y r.t�a' .e,. .•r... - +T. �s�.+�'aFl.....w►.�--.:.e"s;''�►r-`a•- .. . ,.a�Y":�gk[Ttjl�: .t.t.�L"�!.'�'.%�.'.-�,>•.�-•:.r �. r..S:� ...,:Y.T::..a.'-.� - -..,.:;,,•.r..,...
<br /> INItNDER UIIEOF WELL CONSTRUCTION SPECIFICATION* A -h•�`
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<br /> ,,CJ N"ITPAI. ❑OPEN BOTTOM ! DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 'fit D {
<br /> ppp(� ET(CI11"VAT€ JH,GRAVEL PACKMIZE 00 TYPE OF CASINO NBT EELR'VC DIA.OF WELL CASINO A
<br /> IMUNIC I{'AL DrtIVEN DEPTH Of OROVT REAL SPECIFICATION R
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<br /> YO.WAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME fr E
<br /> A�}I�p�q, I GROUT BEAL PUMPED:❑Y*e ❑No CONCRETE PEDESTAL BY DIULLER:EI Y"
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<br /> r- LOCKING CHESTER BOX/STOVE PIPE
<br /> PROPOR TI•Ugj"0NrDF1 UN0 METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER *p 9 f
<br /> I Hfvjf j -c T I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAW , ,D-
<br /> REGULA ,$AIj JOAOURI COUNTY. HOM O R OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'i CERTIFY THAT IN THE PEPFQIM/ANCE OF.Tilt TVOPL( - R YN"l
<br /> ;.:.TIN/PE111pT • Q,I�rAllf P40Y PfR80Np 'ECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CQMFtACTOq•B HIFVNO O^BUB-CbNTRACiIa NONATVNE CERTr1El:'"'i
<br /> • THE ',�,I CEIR1 1r, IN 1, CERFORMA GE OF iL1E WORK FOq vyL11CN TISe PERMIT IS ISSUED,1 SHALL[MPIOV,PERSQNS SUSJECT'TO YVORKMAN'p COMFA/8AT1oi(LAM Or OF.,
<br /> CALF. ►r110pMT, g 1 Ta C/A�"LftQ9.EOR ALL REOUILIE�INe T10N8AT 11 -f47e.'COMPLETE DRAWING1LTJ,OYVEq AREA L'ROV1pEpya+`
<br /> TIUe DI !!I� ate
<br /> 1'1;OT FLAN IV,"to Boole)Seel* to ''-
<br /> 1• NAT11E�TN'�TIIEETI Oq ROADS NEAREST TO OR BOUNDING TIIE Pf►Di'ERTY. '''♦. LOCATION OF NPU/E SEWAGE DIS SAL SYSTEM QI1 I`O6ED
<br /> 2. OWL"pf THE PROPERTY,GIVING DIMENSIONS AND NORTH OIRECTION. EXPANSION OF SEWAGE DISPOSA+HEMS.- t•-
<br /> J.'DIHIENNDHEq PVTLINF.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS W111-11N S OF ON11. �IF-f�'FT,
<br /> eTRURTNR g,MICLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON TIIE PROPERTY OR ADJOIN PEATY, •"-'?l,l; ' yl
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<br /> ACCOUNTINQ ONLY: MDI FACT
<br /> n COQ4; FEE INFO WOUNTItEN11116 CHECKNICASH -RECEIVED BY DATE PERMITISERVICE REOUEST NUMBER INVOfCE'-'c t-
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