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APPLICATION FOR WELLIP MP PERMIT <br /> rte, SAN J13AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALT I DIVISION <br /> P.v:-dOX 388,344 EAST WEBER AVEN E,STOCKfON, _ 9524}1.988 <br /> (2091460-34211 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 Y All FROM BATE ISSUED <br /> (Complete In yriplkeh) <br /> APPLICATION 18 HERE BY MADE TO THE BAN JOAOVIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR 4STALL THE WORK OEBCRIBED.TNI$APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TR f,CHAPTER JJB-1116.3 AND THE BTANb B OF SAN JOAOUIN LINTY/PUBLIC HEALTH SERVICES,EFMRONMENTAL HEALTH DMBIDN. <br /> JOB ADORESBIOR APNI CrT.� C7 CTI `�9'�` Y - PARCEL 81`/yE/ R <br /> Q 4 K �- AODPESB ^90 `PLION�E I �c <br /> OWNER'S NAME <br /> CONTRACTOR v G✓� I w V* ADORE$$�j I f P�N f7E0 <br /> SUB CONTRACTORp <br /> _ C � �"�•,_AODREBB y I^SLA UC PNONE��� <br /> TYPE OF WELLIPUMP, ❑NEW WELL ❑REPLACEMENT WELL ❑MONRORINO i I fnw( ❑OTHER <br /> ❑INSTALLATION ❑WELL BYSTEM REPAIR ❑CROSRLOP"M REPAIR ❑VAPOR EXTRACTmN WELL/ J <br /> ❑Naw❑R.Pdr N.P. DEPTH PUMP VET FT. FIRST WATER LEVEL d <br /> ITYFE OF PUMP( <br /> II��'' ❑OUTAF-AERN([*WELL - ❑OEONRY6ICAL LLI ❑ BOR BORING : B <br /> yq bESTRUCTIbN: <br /> TENDED ■ TPE OF CONSTRUCTION SPECIFICATION A <br /> ❑INDUSTRIAL ©OPEN BOTTOM OIA,DF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> I]DOMESTICIABVATE ❑GRAVEL PACKIBIZE TYPE OF CASINOISTEELXPX DIA.OF WELL CASINO O <br /> ❑PUBUCIMUNICIPAL 1�DRIVEN OEPrN OF GROUT SEAL SPECtMAT1ON R <br /> ❑IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ©MONRORING GROUT SEAL PUFJPEOT❑Yr 11 m. CONCRETE PEDESTAL RY DRRLER;❑Yr ❑N. S <br /> APPROX.DEPTH LOCKINO CHESTER OX/BTOVE PIPE - J <br /> PROODIM CONSTRUCTIOMAWAIUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTSFV THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE BONE INA COROANCE WITH SAN JOAQUIN COUNTY OPMINANCES.STATE LAWS,AND RULED AND <br /> MOULATIbNS OF THE SAN JOAOUIH COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CE IES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,I GHALL NOT EMPLOY PERSONS RUBJECT TO WORKMAN'*COMPENSATION LA OF CALIFOPMA.'CONTRACTOR'S HIRMG OR SUBLONTRACTSPO SIGNATURE CERTIFIER <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 1 SUED,1 SHALL EMPLOY PEF48OWS SUBJECT TO WORKMAN'l COMPO* K LAWS OF <br /> CAUFORMA.' HE PPLICANT M T CALL fI�OURi M ADVANCE FOR ALL REGUmEO INePECTOMe A I 14M3tt�f.�-C-O+M�R^ET�E�OMWINQ AT LOWER AREA NT'De .+� _ <br /> 810".4 X nNe Y D.e. V 3V <br /> (+EDT PLAN Kh—m G.•1.1 S.I.I. 't <br /> 1. NAMES OF STREETS OR ROADS REAREBT TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE BEWARE OISPOSAL SYSTEM OR FTIONJBED <br /> Y. OUTUNE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINED ANO LOCATION OF ALL EXIBTnIO AND MIDPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,MCLUOMG COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY.. <br /> .,.: - <br /> :S�e...,. IGS- :.:�,•�-�� : . .�� �� <br /> JL L <br /> �CIrOL'1'►ty7� �SIC,Y'r�L :. ,� .y�,yr . � <br /> N A YIN <br /> EIVI <br /> 7 <br /> .. _ 0:1995 <br /> j. <br /> �itIV,JUA(i�IfJ'U <br /> s <br /> 1'�BLiCH€AL1h`Sr=H?/IGES - <br /> �NU[Ft07�p}�NT�L <br /> HEALTH{JIl�I510A.+. <br /> DEPARTMENT USE Nlv <br /> APPIipNlen Aa..pled B7 �NN�`• <br /> areal IrwPeartan SY O.te P,-v I—p.atl•n BY D•d <br /> DpnuEll.n Inrpxllan SY b•Ia ' <br /> Cemmentr. <br /> ACCOUNTING ONLY; AIDR FAC/ <br /> PE CODER FEE INFO AMOUNT REMITTED .Ok✓FjCABH RECEIVED BY DATE PEMRITI*EIMCE REOVEBT NLMSER INVOICE <br />