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0 0 �a �y <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TRIpDL:Atel - <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.I III APPTIC AT ION 18 MADE IN COMPLIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER <br /> 9-11 115/,*3./jAND TIIE BTANOAPD0 OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDHESSMRAPNI)�/ V � Z/ IL JA IVJ14 /Z/�/T7/X//l_i CITY :�/y�/i]r� PARCEL RIZEIAPNI <br /> OWNER'S NAME j� 7 YE //1 gis.,,/ ADORERS SA'"! C RnINE I6>o••X88(0 <br /> CONTRACTOR P`K eR7/1S cz-e;i C/� AODMRSP090,<I� �.UCI�3%G1 PHONE( <br /> SUB CONTRACTOR • ADDRESS UCI RHONE I <br /> TYPEOF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MON IONNO WELL 1 ❑ OTHER <br /> ❑ INSTALLATION �WEIL BY TEM REPAIR ❑ CROSS CONNECT�REPAIR 11 VAPOR EXTRACTION��IVVELL I J <br /> ❑N.El roo.l, H.P. , ff DEPTH PUMP SETLa". FIRST WATER LEVEL O <br /> HYPE OF PUMP( <br /> ❑ OUT OF-SERVICE WELL ❑ OEONHY.ICAL WELL 1 ❑ SOIL BORING B'T/��' <br /> ❑DESTRUCTION: �J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INWSTRIAL 1:1 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO <br /> ;TdrDOMESTWIRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINOISTEEVPVC DIA.OF WELL CASINO D� <br /> Cl PUSLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION S <br /> ❑ IMOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PIMPED: ❑Yr [IN. CONCRETE PEDESTAL SY DRILLER:❑Y« ❑N. S� <br /> APPROX.DEPTH �r>^ /,[J- LOCKING CHESTER BOXISTOVE RPE <br /> PROPOSED CONETRUCTION/DWLUM METHOD: MUD ROTARY AIR NOTARY AUGER CABLE OTHER <br /> I HERESY CERTIFY THAT I HAW PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SM JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULE.AN� <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OYJNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTFY THAT IN THE PERFORMANCE OF TIIE WORK FOR WNICIp <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S IIIMNO OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOVANG: 'I C IFFY THAT IN WE PERMP MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMM'.COMPENSATION SAWS OF� <br /> CALIFORNIA: R-R, 1 T MUST1 CALL 11 IN ADVANCE FOR ALL REGUNIM IIlNGMRS <br /> �{AT 12Oe14Y-10422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> BIHIR.I X G �LX tlAP�� TIMI._-1�iCik/ D.1. /J-� / A ✓ <br /> PLOT MN IDr.w 1.5.0.1 B.H. •I. <br /> I. NAME.OF STREETS OR TOADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On pTX,MS D <br /> 2. OUTLINE OF THE PROPERTY,OIVIRA DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSA SYSTEMS. <br /> 10. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PNOPOSED S. LOCATION OF WELLS WITHIN RADIOS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED ARIAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> V4- <br /> X% <br /> ;_. .' ;SSSS: _ ! r2•� <br /> pAh <br /> S <br /> APR 2 2 Gam; <br /> 1 ... i nF:.11;: <br /> t I <br /> ' DEPARTMENT USE ONLY (/rj_J <br /> L11 <br /> ApPBC.11on Ap WIW BY D.H. v Ar« pt 1aY I/� <br /> Glpul ImplFlbll 01 O.0 Amp ImpmS.n BY DN. �V•Z f �T <br /> O1rb�titlan IrnPKIbn BY D.I. <br /> cpmma,G:/o.Zq-44- .9ur.N.�w �/IRTS�(,q,. <br /> U4 <br /> ACCOUNTING ONLY: AID/ FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK( ABN RECEIVED BY DATE POtl.MITISAINCE REQUEST NUMBER INVOICE <br /> 3 X00 IW Q y1z <br />