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APPLICATION FOR WE1t11PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 9M 304 EAST WEBER AVENUE. STOCKT'ON. CA 55201388 <br /> (209) 466-3420 <br /> r NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete In Trilirwata} <br /> UIPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANRIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAH <br /> :OAOUIN COUNTY DEVELOPMENT tTITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC tHEALTH SERVICES.ENVIRONMENTAL,HEALTH DMSION. ' <br /> 'OBADORESSMR APPN. O 1 N 5� Crry 1 kT�/'1C. PARCEL BQEJAPH/13-41 —45,� -3 <br /> 1 —30 - <br /> IWRIER'B NAME l D� �l 'I .l--ate` ADOREnn C) �Ox Y �3 PHONE r� Lot Dg ! 1 <br /> R <br /> :ONTAACTOR {{�7� �1n�VJ(1ro+c-Cc l ;f"� l/y� AoomesC. b e•. tic r 'O X01%k PHONE l .53O� <br /> ;UB CONTRACTORY Y VQI.���'� 1 � )o' ���1�� ao- ADORES8 J,i2ZLZ <br /> LICA � PHONE# <br /> i <br /> yn OF WELI�PUMP. ❑ NEW WELL ❑ REPLACEMENT WELL �AONr roF4mO WELL I_�L ❑ OTHER <br /> ❑ MBTALLATON ❑ WELL SYSTEM REPAIR ❑ CAOSS-CONNECT REPAIR ❑ VAPOR.D07ACTION WELL,/ j <br /> ❑New❑Rapdr H.P. DEPTH PUMP BET FT. - FIRST WATER LEVEL - O <br /> TYPE OF PUMPI <br /> © OUT•OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ SOIL BORING - @ <br /> DEBTRLI[TION; . <br /> 4IENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS .A <br /> J P=STFIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �l,�Y\`�f DPA.OF CONDUCTOR CASINO D <br /> I DOMEBTICIPRIVATE ❑GRAVEL PACXMtZE TYPE OF CASINGMTEEUPVC VVC DIA.OF WELL CASING IR O <br /> J PJSUCIMUNICtPAL RDRIVEN DEPTH OF GROUT SEAL tt__ ` SPECIFICATION <br /> 3 IRRIGATIONIAG ❑OTHER GROUT SM 1NSTALtED BY �DORA W 1 `1 Il OROIFT SRAHO NAME O W� <br /> -MONITORING j GROUT SEAL PIMPED: Vr ❑RRa CONCRETE PEDESTAL BY DRILLER:❑Yr ❑No S+5 <br /> ,PPnoX.DETIH - .LOCKING CHESTER BOX)STOVE RPE C) is ,J <br /> gGraSE>5 CONSTRUCTIONID1tlLLIN0 METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER nE <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ARID <br /> EGULATIONS OF THE SAN JOAOUtN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> HIS PERMIT to tneUED,r SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> HE'FOLLOWING: -1 CERTIFY THATIN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'*COMPENSATION LAWS OF <br /> ALIFORNIA.- THE MUST CALL 24 HOLIAS IN ADVANCE FOR ALL REOUMm I"NNAM'IONS AATr1.2451 4SS-342]. COMPLETE DRAWING AT LOWER AREA 77!�:l <br /> yrr d X - _-- n'k T'E1V, 1 ""'� "Y'. - - Dat. <br /> ROT PNU/#Draw to Basle)Scala 'ee <br /> NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. - 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> OUTLINE OF THE PROPEI4TY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> DIMENSIONED OUTUNF"B AND LOCATION OF ALL E%tvnmG AND PROPOSED 5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> 47RUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> .......:......:..............:.....................:.....a......;.... .. .. .. .. ... <br /> ..:.....:::.. <br /> .......... <br /> ............:...........:.. ...... <br /> D£PAATMVff USE ONLY <br /> raileetlon Aooeeted BY ~ -.. Data 7 - Aro - <br /> J <br /> out Impeetlon By6 Date Pump Irrsoctlon By Date <br /> ­trta:Non inawot <br /> Data <br /> n - <br /> ACCOUNTINO ONLY: ��,- AIDS FAC# <br /> ` <br /> INF ; <br /> PE CODES FEE O _ '`AMC UN7"A?-KTTW CH ASH RECErVED BY DAYE P81MlTIZERV10E REQUEST NLIM111 l ' INVOICE <br /> d ,� az3 /" <br />