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-��So _ APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> R0. BOX 3618,304 EAST WEBER AVENUE,STOCKTON,CA 95201368 <br /> (2091 468.3420 <br /> FOX-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM Wk ISSUED <br /> (UmpIBb In Trlplinb) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PFTSAIT TO COMGTRUCT ANOfOR INSTALL THE WORK DESCRIBED.THIS APPLICATION m GE MAIN COMPUANC!MATH BAN <br /> JOAQUIN tM <br /> COUNTY OEVELOEtNT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH ORR ON. <br /> Joe ADORt69/0.R Aq1/ T � � � �1 CN. ( d crry l � '1"�T �moi, 7 7QC'/Yj <br /> �/ /l�,y�] /�. 'y/ / PARCR SRElAPFY <br /> OWNER'S NAM AJ /,L L�/•PSP{fir/ 290 6, •v:. ����C�� PHONE 3 <br /> AOOIIESS <br /> COM FACTO —Arx LI`- <br /> ADDIESS LVC r E' -'WIr.0�� UC/ I�.� . <br /> BUB CONTRACTOR ,,.,� ADDRESS uC1— PHONE IF <br /> TYPE QF WElLP1MP• L4'T NEW WELL ❑ REPLACEMENT V/Ell ❑MONITORING WELL/ ❑OTHER_ <br /> �❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROASCONNECT REPAIR ❑ VAPOR[X-pACTION WtLL I <br /> N.A'❑148W N.P. \�. DEPTH PUMP SET�FT. FIRST WATLR LEVEL p <br /> R VPE OF PUMP) <br /> Cl WELL ❑GEOPHYSICAL WELL E ❑ SCR BORING S <br /> Cl OEBTRVCTION: <br /> ! DED�41 TYPE Ory— <br /> JQ, CONGTRUcTION SPKIF)CkTuO A <br /> 1 ❑INDUSTRIAL ❑OPEN BOTTOM jj DIA.OF WELL EXCAVATION Z-e it WA.OF CONDUCTOR CASINO <br /> 11 <br /> DOMESTIC/PISVATE R7 p.[lRAVEI PACK/817F 1•'•` TYPE OF CABINO/STEEUPVC S &c ( IMA,OF WELL CASINO <br /> �N,❑.M(f RWPUSUC/MUNICWAI ❑DRIVEN DEPTH OF GROUT SEAL. S/' 1 I _ SFECIFICATbN " R <br /> K <br /> I IOATION/AG ❑OTHER GROUT BFAL INSTALLED BLY�-T(-(4/11` _ GADUT BRAND NAME Ir'S'" `S�- E <br /> ❑ M' <br /> � <br /> 1 MOORINO GROUT DEAL OG <br /> PUMPED.0-f----ON.N. CONCRETE FEDESTAL BY GRILLER❑y- ON. S~ <br /> I A►PROX, <br /> DEPTH LOCKINGCHfSTER BOA/STOVE RIE pp�� �j�P7 y� S W <br /> PROPOSED CONSTTIVCTIONMAILDNG METHOD: MUG ROTARY_ AIR ROTARY AVOER_ CABLE OTHER 0Vl r Z F A <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED VMS APPLICATION AND!HAT THE WOFK WILL BE GONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STARTS LAWS,AND BULLS AN <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LK:NEED AOENT'8 SIGNATURE CERTIFIES THE fOLLOWNG:'1 CERTIFY THAT N THE FENPOISAANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IB ISSUED,f APPALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPETMSATION LAWS OF CA'.1FOMIA,• CONTRACTOR'S HIRING OR WIBCONTRACTNO 91ONATUIIE CERTIFLES <br /> THE FOLLOWNG: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WONX FOR WHICH THIS PERMIT IS ISSUED,1 WALL EMPLOY PERBONS SUBJECT TO WORMAN•S COMPSNSATON LAWS 112 <br /> CALIFOI IAA.' THE APPLICANT CALL b HOURS IN ADVANCE FOR A!1 REOLllltm INS P[C NB AT IJ'PIPPRO" <br /> )440.8178,COMPLETE DRAWING AT LOWER AREA PRODEO. <br /> �� �y Gly � <br /> 810—d X i ( �l`+i/L_J <br /> 1-3,[� hu RC2 L. D.:. )fes `-L--C <br /> PLOT PAN'0' to S*`*6"16 •to <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DIBPOeAL SYSTEM OR F'RIOPOSED <br /> I. OLRLNE Of THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DBPORM SYSTEMS. <br /> J. (MMENBONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DPVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> Ft3�1 S+tsikAT: <br /> :. <br /> (^ . ARS - 9 1997 0. <br /> i <br /> 1� <br /> . <br /> ki <br /> 3 <br /> DFPAATMENT USE ONLY <br /> APPlio.tlon A—,,W Sy_ v.t. —7-A,--� <br /> G...A hnPecum Br_ D. S 4 P,—P Irrp-Ileo By <br /> D—ee.�.bn M.P.PlI.r.fly OHe <br /> 1 <br /> CommanH: C� D 0 A./w�w <br /> :<.o ►R i3 caaA o� Coo �� a.S'�vS L bid Co4s- <br /> ACCOUYDNO ONLY: AIpF FACT <br /> Pf DFEE INFO AMOUNT REMITTED CHEC ASH RECEIVED ST DATE P9MIITl INVOICE <br /> 1 CO :61 ( go D a <br /> �So zl p 4 <br />