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APPLICATION FOR WELUPUMP PERMIf' <br /> C t p7 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> MOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> (CmnplelE In Tripiketel <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUtN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WOFK DESCRIBED.TIIIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DMLOPMLE-NT TITLE. <br /> CHAPTER <br /> /�B�-1 116.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC IIFAALTT14 SERVICES.ENVIRONMENTAL HEALTH DIVISION, <br /> JOB AOORESSIOR APNI J 1 W I I A- Ir!L r o ' CITY ��(/(_ J IJ J f l/ e / PARCEL SIZF/APN/ Q y� <br /> OWNER'S NAME L ADORERS-� _ ' Vn VI'1 T ! I F.H.I. <br /> CONTRACTOR 1' V Z Com' tqp1)Ar l I- . ADOMIRI 1414 mail, PHONE I 839_1719w <br /> � D w - - 0 S,3 }aPUBCONTRACTOR r , ADO/E88 L1Cl y0- te <br /> V I <br /> TYPE OF WEC3 NE <br /> LUPUMF-, W WC111ELL REPLACEMENT WELL MOD <br /> NORINO WELL I V ❑ OTIIER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F <br /> ElNo-11neo o H.P. DEPTH PUMP SET FT" FIRST WATER LFVEL O <br /> h VIPE OF PJMPI <br /> ❑ <br /> OUT-OF-SEnVICE WELL ❑ GEOPHYSICAL WELL f SOIL BOTINO D�3 <br /> a <br /> U OFAlRI/C_TION: <br /> INTENDED VSE TYPE OF WELL CONSTRUCTION SPECIFICAIIONS I A <br /> ❑ INDU97RIAL ❑OPEN SOT-TOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOn CASINO O <br /> ❑ DOMFSTIC/PRIVATE ❑ORAVEL PACKMiZF TYPE OF CAS..GMTEELJPVC DIA.OF WELL CASINO D <br /> I <br /> C1P79LICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL - SPECIFICATION S <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INRTALLEDAIY Lon f(Z(C{Ur OROIR BRAND NAME p <br /> Cl MONITORING OROUT SEAL PUMPED:XY.• 'INo CONCRETE PEDESTAL SY DRILLER:❑Y_ ❑Ne S <br /> APPROX. DFFTH LOCKING CHESTFn BOX/RTOVE PPE <br /> S <br /> PROPOSED CONSTINUCTION/D111LUNO METHOD: MILD ROTARY AIR ROTARY AUGER_ CABLE OTHER <br /> I Off-FRY CERTIFY THAT I HAVE PREPARFO THIS APPLICATION AND THAT 714E WOR(WILL HE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> nFOULATIONB OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AOENT"S RIONATuM CERTIFIER THE FOLLOWING:'t CERTIFY THAT IN THE PERFORMANCE OF T11E VJOW FOR YNIICII <br /> THRI PERMIT IR IRRUED,1 9HAI1.NOT EMP.OY PERSONS SUBJECT TO WORKMAN'S COMPFNSAT70N LAWR OF CALIFORNIA.' CONTRACTOR'S IIIrINO OR RUB-CONTRAC_TINO SIONATUnE CERTIFIER <br /> THE FOLLOWING: 'I CERTIFY THAT IN TIIE PERFORMANCE OF THE WOrW FOn WHK'11 THIS PFRMIT IR ISSUED.I RHALL EMPLOY PERRON9 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MV CALL 24 All.IN ADVANCE FOR ALL 1111111".INS►ECITONS AT 110100-311421. COMPLETE DRAWING AT LOWER AMA PROVIDED, 9 7y'1� <br /> MSn.d X lLeof/U DN. ( ` (/ <br /> PLOT PLAN RN—1.9a•I.1 S-1. 'to <br /> 1. NAMES OF RTRFET8 OR ROADS NEAREST TO OR ROUNDING THE Pr1OPERrY. 1. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> Z. OUTLINE OF THF PROPERTY.GIVING DIMENSIONS AND NOFITH DIRECTION. EXPANSION OF SEWAGE TXSPOSAL SYSTEMS. <br /> 1. DIMFNSIONED OUTLrNFR AND LOCATION OF ALL EXISTING AND PROPOAEO E. LOCATION OF WFt19 WITHIN RADIUS OF ONE HUNORD FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AN PAT10110,DREVEWAYB,AND WALKS. ON THE PiOPERrY On ADJOINING PROPERTY. <br /> .... ..... .,... .. <br /> ................._........ .....:............................. ........... ........... l; <br /> P��/L/� DEPARTMENT USE ONLY <br /> 4J��1/;�// <br /> O.eu1 In•Pnallen BY D.0 Pon.In•owetlen eY D.1. <br /> D.wbvcllen L..nenele..Rn�r yy y I �( D•1• <br /> Ce.nmmP1•• 3 /ll/a L&1"/L- 1j,_el%�-- .!1/�t �' (�:.,../nA-Itt <br /> ACCOUNTING ONLY: AHO/ MC• <br /> 1 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKItCASH ItEC13VFD EY DATE pff"11111IF71VICT REQUEST NUMBER INVOICE <br /> YS <br /> Pub.Health Serv.-EnvirO. 173(1197) <br />