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13 <br /> 1PLICATION FOR WELUPUMP PERMIT IGINAL <br /> SAN�OAOUIN COUNTY PUBLIC HEALTH SERV1'C,`E s <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468420 <br /> — NON•REFUNDARLE PERMIT EXPIRES 1 YEAR F �AIIN <br /> c�►p f�r���c�S R RDM DATE ISSUED <br /> l� ti ICaBrgIBtB fn Tr�IieatBi <br /> APPLICATION IS HERE BY MADE TO THE BAH JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOXIR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE-IN,-COMPUA.KE%N STH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-111 5.3 AND THE STANDARDS OF SAN JOAOUBN COUNTY PUBLIC HEALTH SERVICER,mvmINMENTi1tT-HEALTH amo N. <br /> T <br /> JOB ADORESBJOR APNE - ,,I CITY J 4, ,.7�/j�/�J/ fPARCEL StMAPNO _ S <br /> OWNER'B NAME ' U Q I !` ADORE88 �` D O 7'^,,f., Ir" 4. -L53- l E -7 <br /> CONTRACTOR ev 4- / - ADDRESB_po&C 3'n 4�.--/�s. �ldif�/��'7IOL PHONEA' Q6z <br /> SUB CONTRACTOR ADDRESS IJCI PHONE/ <br /> TYPE OF WELLJPUMP: ❑ NEW WELL ❑ R LACENIENT WELL ❑ MONITORING WELL R ❑ OTHER <br /> AJ <br /> A- ❑ INSTALLATION 13WELL SYSTEM REPAIR ❑ CROSWCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> ❑H.w❑Ft.W H.P. DEPTH PUMP GET FT. FIRST WATER LEVEL p <br /> RYPE OF R1MPI <br /> 3 ❑ OUT-OF-SERVICE WELL ❑ OEO/PH/YS?CAL WELL EI u� GOII BORHO� TT riQ f[ Ir <br /> L_.�r[ <br /> ❑OESTRUCTKIN: D! f 1�I y •L[1 e„ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECWCATIONS A <br /> ❑ INOUSTRAL ❑OPEN BOTTOM DIA.OF T E7<LR411TION AJ n 5 DIA,OF CONDUCTOR CABING N D <br /> ❑ DOMESTICIPRVATE ❑GRAVEL PA.CKJSI2E TYPE OF CASINOMTEELMvc N DIA.OF WELL CASINO N f/Q O <br /> ❑ PUBUCIMUNICIPAL ❑DRIVER DEPTH OF GROUT SEAL7-0 --14-12 <br /> "14' SPECIFICATIOm A,' T R <br /> 11IMOATI0NIAG 13HE <br /> OTR GROUT SEAL INSTALLED BY 41'9411' GROUT BRAND NAME F <br /> ❑ MONITORING �J GROUT SEAL PUMPED: ❑Y. ❑N. CONCRETE PEDESTAL SY ORLLERr❑Yr t❑Hr S <br /> AP PPW X.DEPTH `[�-S� 6aS LOCKING CHESTER OOXMTOVE I/` LL S <br /> F"OPOSIM CONSTRUC"ONIDI ILLINO METHR A_`7!OD; MUD ROTARY AIR ROTARY AUGER CABLE OTHER /V <br /> 1 14MRY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOVIN COUNTY ORDINANCES.STATE LAWS.AND RULES AHD <br /> MOULATIONS OF THE SAN JOAOUII COUNTY. HOME OWNER OR LICENSED AGENT'S=NATURE CERTB9E@ THE FOLLOWING:-I CERTIFY THAT IN THE PEWOPSMANCE OF THE WORK FOR WH}CH <br /> THIS PERMIT It ISSUED,I SHALL NOT EMPLOY PERSONS BUBJECT TO WORKMAN'S COMP9PSATTON LAWS OF CALIFORNIA.• CONTRACTOR'S NetNG OR BUS-CONTRACTI O SIGNATURE CERTIFIES <br /> THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PEWATT IB ISSUED,1 @HALL EMPLOY PERSONS I JI&ACT TO WORK MAIP'S COMPENSATION LAWS OF <br /> CALIFORNIA'' THE APPLICANT MUST 24 HOW IN ADVANCE FOR ALL RECURRED INSPECTION@ AT 1 //1(4094422..l�COIM�PLETTE DRAWING AT LOWER AREA PROVIDED. <br /> Stur-d X WLI/ TI"o Al �s� lJ e-0 YJ_7 a•.}/ . ._,. Dm.�L �{,.ii._ <br /> PLOT FLJIN mrr to Saw.R S..Rr •» <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDRHO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE OMPO/AL SYSTEM OR PROPOSED <br /> I. OUTLINE OF THE PROPERTY,OPANG DIMEH/ION@ AND NORTH DIRECTION. EXFARMN OF @EWAOl bI@Pl7SAL SYSTEMS. <br /> 3. bIPAEH810NED OUTLINES AND LOCATVN OF ALL EXR MNG AND PROPOSED S. LOCATION OF WEI.LSI WMRNIH Piume OF RE <br /> ONE HONORED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SACT!AS PATIO$,ORVEWAYS,AND WALKS. ON THE PROPERTY OR ADJO@RPIG PROPERTY. <br /> DEPARTMENT USE DNLY <br /> Appllr.tlen Apoats»d BY <br /> Gma 1-owtb..BY O.te Pl p In"e.nt-BY D.Ir <br /> b.rt.twl..f'w-tl.n BY <br /> EVED <br /> ACCOUNTINO ONLY: ARDI FACE op -dw <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKIJCASH RECEIVED @Y OATS PERM11TISERVICS REOMT NUMBPJL INVOICE <br /> lie <br /> Pub.He@!th Serv.-Enviro.173(IAM <br />