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SAKI JOAQUIN COUNTY PUBLIC HEALTH SERVICES " k <br /> ENVIRONMENTAL HEA DIVISION D <br /> 304 EAST WEBER AVENU , TOCKTON, CA 95202 <br /> (2M 468-3420 � I <br /> NON-REFUNOAKE PERMIT EXPIRES 1 YEAR FROM OATE ISSUED <br /> ^'r 1Gm INh <br /> APPLICATION 10 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WOFK DEdCFIBEO.THIS APPLICA71DF1 Lg WADE TN COMp1,JA?I[E WRH BAN <br /> JOAOUIN COUNTY DEVELOPMENT TTTLE•C34APTEFI 8-1116.3 AND THE STAND g OF BAN JOAOUIN COUNTY PLMM HEALTH BERVICEB,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADOFIESSIOR APHIPARCEL S2FJAPHO d — <br /> OWNER'S NAMElip AODPEgN "' ., ^• S�.S 1i10NE <br /> CONTRACTOR G ADORERS V UCf�FHONE <br /> 1 k <br /> PHONE <br /> HiCOHTMCTOn I ADDRESS UC1 <br /> lt! / l <br /> �l�,�� 5 <br /> TYPE OF WELLJPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL MOMTOPWO WELL I�a [.D ❑ OTHER ` <br /> ❑ <br /> INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EJTTRAcmN wET.L! ,/ <br /> G <br /> ❑N—❑aww, H.P. DEPTH PRIMP SET FT- FIRST WATER LEVEL O <br /> (TYPE OF PUPAPI <br /> ❑ OUT-0F-00VICE WELL ❑ GEOPHYSICAL WELL A ❑ SOIL Bomm S 1. <br /> ❑DESTRLMTIOFh <br /> INTENDED USE 7YPE OF WELL CONSTRUCTION SPECPI ICATIONS f' A <br /> ❑ VROUITTRIAL ❑OPEN BOTTOM DIA_OF WELL EXCAVATION DIA_OF CONDUCTOR CASINO D <br /> ❑ DOMESTICIPMVATE GRAVEL PACRJBRE TYPE OF CABINOlSTEEI.JPVC OIA OF WELL CASINO p <br /> ❑ MMCIMUNICIPAL DRIVEN DEPTH OF GROUT SEAL SPECIFIC.ATTON q <br /> ❑ IPMOATIONRAG ❑OTHER GROUT SEAL INSTALLED BY GROLR 1.1 NAME E <br /> 1vr <br /> ❑ MONITORING GROUTL3 SEAL PIMPED- Y— [IN. COCRETE PEDESTAL BY c Rd LEFh❑Y— Ns s F <br /> (l�'f <br /> APPROX.DEPTH LOCKING CHESTER BOx1R <br /> OVE PIPE I S { <br /> PROPO NEO CONSTRUCTIO NIDIILLRNO METHOD! MUD ROTARY AIR ROTARY AUGER CABLE 11 OTHER { <br /> I HE'ERY CETITtFY THAT 1 IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE YOM BAN JOAOUIN COUNTY ORDINANCEI.STATE LAwo.AND RULER AMC <br /> REGULATIONS OF THE BAN JOAOUIH COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWRIO:'I CERTIFY THAT IN THE PETIF PIMANCE OF THE WORK FOR Vw"CH <br /> THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOR"AAN'N COMPENSATION LAWS OF CALIFORNIA.' CONTRACTORS FARING OR SU"ONTRACTING MMATUFM CERTIFIES <br /> THE T-OLLOVANG! •I CER,MY THAT IN THE PEPFOFIIAANCE OF THE WORK FOR WHICH THIS PERMIT IB IBSUI D•I SMALL EMPLOY PERSONS SVBJECT TO WOR'aMAX'$COMPfl7NATTON LAWS OF <br /> - CALIFORNIA.' THE APPLICANT M CALL,TI HOURS IN ADVANCE TOR ALL PW UI IED NNP4CTIDNN AT I2S'N1 4NS.yAYi. COMPETE DMWSRO LOWER AREA PRO EO. <br /> BIQ.+d x TIN+ <br /> - ROT PLAN ID—is geld Sod. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR KnmmmFRT THF PROPERTY. 4. LOCATION OF HOUSE SEWAGE ORTPONAL SVS7EM OR PROP a M <br /> 2. OU`TLNE OF THE PROPERTY.GIVING DSUETIMRS AND NORTH DI ECTIOH. EXPANSION OF SEWAGE DISPOSAL SYTTTEMS. <br /> ]. DMAENSIONED OURINES AHD LOCATION OF ALL EXISTM AND PFIOPOWD N. LOCATION OF VKLLZ WTTF#i R'AMMI OF OW H%MDFED FIFTY R. <br /> STRNCTUTES,NCLLIDING COVETED AREAS SUCH AS PATFOI,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR AMONING PROPERTY. <br /> : <br /> - ._,. ......- ...... _. r <br /> ... ..- <br /> . .. ...:......... .. .........°.. <br /> v.!`•'.. <br /> ..... ........r.- ...... <br /> - _ - <br /> : : <br /> I <br /> DEPARTMENT USE ONLY <br /> Appa=-rten Aoe.atd By r yJ r �r 06 <br /> ba. / ti V (f <br /> anew k+.oeaelen Sr Dow P"tlen BT <br /> D.t■ <br /> De�levetlwl <br /> DHo _ <br /> ACCOUNTING ONLY: / <br /> FACS <br /> PE CODES- FEE INFO AMOUNT RMTTED CHIMUMAINH RECEIVED■Y DATE .. <br /> P6I{AITlNERVICE FtEGT/E1T HLNIAN@I INVOICE <br /> its Ae <br /> v r <br /> Pub.Heaft Setv.-Er*OL 173(1/97) <br />