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APPLICATION FOR WELE IPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBL C HEALTH SERYL <br /> ENVIRONMENTAL HEAl TH OIVISION <br /> r-A BOX 988,304 EAST WEBER AVE 4UE.STOCKTONI CA 9=1 388 <br /> 12031 469-31 20 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICDmplota In Trk Rats) <br /> APPLICATION IB HERE RY MAOF TO THE AAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AMOK R INSTALL THE WORK OEBCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN <br /> JDAGIAN COUNTY DEVELOPMENT TITLES.CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAGIRF COUNTY PUBLIC HEALTH RERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOS AOORESRIOR APNi S5� C �hl�d;1` �OJ. �� � `�� MN 19 <br /> �a Cr Ry!' ` C 1 PARCEL SI2ElAPPIi <br /> OWNER'S NAMf Ct O She V� AOOTIERR 1 `_. I .DorO� JF Y� PHONE F 93 T- $bag <br /> l lL]L �Or Orw� *�C..' ADDRESS x HCI 11 PHONE 01(2'&"O"j <br /> CpN'TRACTO G ry <br /> 1, <br /> AUS CONTRACTOR C v T'O AVORE6 Z'kZO M�^ '4O L1Ci�D�gO PHONE <br /> FPTY f O�W; ❑NEw WEtL 13 REPLACEMENT WELL ❑MONITORIND AFELL IF ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR' ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL F J <br /> ❑Ns..13Rep.Ir H PPf <br /> M.P. OEH PUMP SET TT, FIRST ATER LEVEL d <br /> (TYPE OF PUMPI <br /> ❑OUT-OF-SERVIC£WELL ❑GEOPHYDI[ WELLi SOR BORING B <br /> ❑DEBTRUCvow <br /> VITEN E USE VYPE OF WELL CONSTRUCTION SPE0FICAD)Nt A <br /> ❑INDDBTRIAL ❑OPEN BOTTOM DIA.OF WELL FXCAVATION DIA,pF CONDUCTOR CASING D <br /> 0 OOMESTICIPRIVATE ❑GRAVEL PACKIS02F TYPE OF CASING/STEELIPVC DIA.OF WELL CASING 0 <br /> ❑PUSLICIMUMCIPAL ❑DRNEN DEPTH OF GROUT DEAL SPECIFICATION R <br /> ❑IRRIOATIONfAG ❑OTHER GROUT REAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONITORING GROW SEAL PUMPED:❑Y ❑N. CONCRETE PEDESTAL EV bRRJFR:❑V- ❑N. 5 <br /> APWIOX,DEPT LOCKING CMESTI R BOXMTOVE <br /> PRG►OSED CDNSTRUCTIONIOSWNG METHOD: MVO ROTARY AIR RDTARY AUGER CABLE OTHER�� V <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE M ACCORDANCE WITH BAN JOAGIAN COUNTY ORDINANCES.STATE LAWS.AND RULES ANO <br /> REGULATIONS OF THE DAN JOAOUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOYNNO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOWFOR WHICH <br /> 1 THIS PERMIT 16 ISSUED,I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'*COMPENSATION LAWS OF CALIFORNIA.'CONfRACTOR'e HIRING OR RUB-CONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF TME YYOW(POR WHICH THIS ITRAIT M ISSUED,I SHALL EMPLOY PERBONS SUBJECT TO WOROAAN'S COMPFNSATION LAWS OF <br /> CALIFORNIA.- THE`ApFYC111 MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURED INSPECTIOPIB■ 2IIB!�SS1��„.I�71�,$.`OMREeYEI� WINO AT LOWER AREA PROVIDED. <br /> Ble-A It <br /> ROT PI.AM BN.w to Be.l.!Ded. le <br /> 1. NAMES OF STREETS O ADS N AndrT TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYRTEM OR PROPOSED <br /> 2.OUTLINE OF THE WIOP'F DIMENSIONS AND ROM"DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMFNAIDWO OUTLINES AHD LOCATION OF ALL FXIRTING AND PROPOSED D.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY PT. <br /> STRUCTURES,INCLUDINO COVERED AREAS SVCH AB PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> - <br /> i <br /> ' DEPMTMENTUSE ONLt <br /> APpgwllen Ae..pted SY D.t. �•"�� `I" Mr <br /> areae S+ap.mlen Sf b.ta P—p p.p-1 1..BY On• <br /> Dwtn.6-Ln.pe I_Sy Dae. <br /> Com�nenl. . <br /> 't ACCOU7TINO ONLY: AIOI FACE <br /> PE CODER FEE INFO AMOUNT REMITTED CHICKOXABN RECEIVED BY DATE ►91AOTIBIRVICE REOUEBT MVMDER INVOICE <br /> 3sa� 5+�3�9 ll 0LQ Z TO <br />