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( PPLICATION FOR WELLIPUMP PERW <br /> SAN jOAQUIN COUNTY PUBLIC HEALTH SERvICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Cempllt{ in TripBcst!) <br /> APPUCATION 18 HERE BY MADE TO THE SAN JOAOUR/COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TILS APPLICATION 16 MADE IN COMPLIANCE MTll SAN <br /> JOAQUIN COUNTY DEVELOPMEENyeTT7_TITLE <br /> �j.CHHyA,PTEER 9,-„1_116-..3 AND THE STAHOARD9 OFA JOA�FT COUNTY <br /> �PUBLIC <br /> ,HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> � <br /> JOB ADORESMI't APNI <br /> 1-4-"—"—' r�”' (�✓//'7 / '�i IZ�`�� h ICIrYn / /�i G� PARCEL SIZE/APN/--;)V6� <br /> OWNER'{NAME / G ADORE{{ f�� �}(PHONE I <br /> CONTRACTORApp�pG VC-� <br /> AVB CONTRACTOR ADORE" UIC! PHONE I <br /> TYPE OF WELL/PUMP ❑ NEW WELL ❑ FV"CEMENT WELL ❑ MOWTORNO WELL! ER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL I J <br /> ❑N—❑R.odt H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> R YPf OF Pl1MP) `Uy� <br /> ❑ OUT-oF-SERVICE WELL ❑ GEOPHYSICAL WELL! Jr,F SOIL SO <br /> E ✓' g <br /> ❑DESTRUCTION: !!! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA-OF WELL EXCAVATION OF CONDUCTOR CASINO 0 <br /> ❑ DOME9TICIMVATE ❑GRAVEL PACXISRE TYPE OF CASR/G/STFEUPVC DIA.OF 0 <br /> ❑ PU8LJCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL V'ECtFICATION R <br /> ❑ IRRIOATIONIAO ❑OTHER GROUT TEAL MHTALIED BY GROUT BRAND NAME E <br /> A MONITORING GROUT SEAL PUMPED: ❑Yoo ❑N• CONCRETE PEDESTAL BY DWLJfPI•❑Yon ❑N. 5 <br /> 1 <br /> APPROX.DO"M / LOCKING CHESTER BOXXTOVE PWE S <br /> PROPOSED CONSTRUCTIONMMLUM13 METHOD: MUD ROTARY AIR ROTARY AUGER CEn_ CABLE OTHER <br /> I HE-ELY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUtN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> nEGL1LATIONS OF THE SAN JOAOUIN COUNTY. IIOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRNO OR SUB-CONTWtCTIiG SIGNATURE CERTIFIES <br /> THE FOLLOWING: I THAT BI TIDE PERFO Of THE WORK FOR WHICH THIS P£RMfi IS 1{Bt1ED,I{HALL EMPLOY PERSONS SUBJECT TO WORgM AN'S COM►1FNSATION LAWS OF <br /> CAlJFORWIA.' T ANT MV 1 HO M VANCE FOR ALL REQUIRED 1 NS AT 12/0/{jreMJ12! OMP�ETE 0MW1N0 AT ROWER AREA PROVIDED <br /> Stp..•A X Tltl. �� ✓ D.t• C D �� <br /> PLOT FLAN 10r.w to So•I.1 S.•I. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. /. LOCATION OF HOUSE SEWAGE 048POSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,OIVI►IG DIMENSION{AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION Of ALL EXISTING AND PROPOSED {. LOCATION OF WELLS WITHIN RAOIV•OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES,INCLUDING COVETED AREAS SUCH AS PATIO{,DMVEWAYI.AND WALXS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> i <br /> • t <br /> A <br /> AoDE7MTMMT VS[ONLY 4 Q <br /> .11a•eb.. o•epI•d BT ION• (i A... <br /> O.•A 4+.P 6—By Dot• A/eM ln•!•NR•II SY D•t• <br /> O•t• <br /> ACCOUNTING ONLY: AID! FAC! <br /> IE CODES FEE INTO AMOUNT REPATTED CHECKPICASH RECEIVED{Y DAT PEN.BT/SEITVICE REQUEST NLWREFI INVOICE <br /> Pub.Health Serv.-EnvirD.173(1/97) <br />