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APPLICATION FCR %ELLIPUMP PERKII <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 45241388 <br /> a09) 466 3420 <br /> NOR REFUNDABLE PERMIT EXPIRES I YEAR FRDM DATE I3SM <br /> .*Mp4H ti IRo:-L11 <br /> ATgH IB MK BY MADE TO 1.1tSAN-.—IN COUNTY FOR A PERMT TO CONEY RUCT AND/OR INSTALL THE WORK DESCRNCE%R <br /> SED THIS APPLICATION It MADE M COMPLIANCE SAN <br /> AOL COUNTY DEVELOPMENT TITLE CHAPTER 9 1 1 1 S 3 AND THE STANDARD%OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 71 { 1' 4-e (5//P f '✓ 1 c— 1 rJ PARCEL SLxEJAPNO <br /> Joe POOR E—PA A�A..N/F / <br /> OVJNFFI B NAME ! ! r J r r,_/ / // 1 — — ADOIIEse C�Jt. ✓� e fz <<��—rMNE �cr ttf r/,r f_ <br /> CONTRACTOR/ / fl� .:1 T_' _ ADCFIC66/ // /yl/ / !/tic, PHONE I,���riJ /ILP <br /> Suit CONTRACTOR ! �� ♦r '/ r� / /' / / f ADORE to t r --—LIC, PHONE■ <br /> Of NIFLLAYIMP ❑NEW WELL ❑REPLACEMENT WELL p MONITORING WELL F OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CRO6$-CONNECT REFAIR ❑ VAPOR EXTRACTION WELL F J <br /> ❑N..r CJ <br /> ft-dr HP Of PTH PUMP$"_FT FIRST WATER LEVEL 0 <br /> TTYPE OF PUMP) IR----II <br /> ❑OUT-0F SER E WELL ❑OEOF'HYSRCµWELL 1 LJ SOI/BORING S <br /> �37DESTRICTION /f / / I ri / r .1 (c r, �r i — r l r. <br /> /MENDED U6F TTYK OF WELL r CONSTRUCTION■PECIHCAIWNS A <br /> ❑ INDUSTRu 11OPEN BOTTOM DIA OF WELL EXCAVATION D <br /> / I OIA OF CONUCTR OCASINO O <br /> }Cl DOMESTIC/PRIVATE 13GRAVEL PACKI$IZE TYPE Of CAFNGALTEELJPVC //f / dA OF WELL CASINO D <br /> U PUbIEC/MUM..I-AL 13ORVEN DEPTH OF GROUT REAL SPECIFICATION A <br /> ❑ IRRGATIONJAG 11 OTHER f GROUT SEAL INSTALLED BY E� GROUT BRAND NAME IF <br /> ❑ MONT1:1DNNG ` GROUT SEAL PUMPED Yr ❑N. CONCRETE PEDESTAL BY ORLLER.❑Yw [IN. S <br /> APPRO). DE H LOCKINO CHERTER 6OXMTOVF PPr S <br /> PROPOSIED CON6rRUCTIONRNSLNIEG METHOD MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HTREBY CERTIFY THAT I HAVE PREPARED THIS AlllLXATK]N AND THAT THE WOFK MALL DE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES STATE LAYM AND RULES AND <br /> REGULATIONS OF TME BAN JOAOUIN COUNTY HOME OWNER OR LICENSED AGENT■SJONATURE CERTUIES THE FOLLOWINO 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED 1 SHALL NOT EMPLOY PERSONS SU6JECT TO WORKMAN A COMPENSATION UWS OF CALIFORNIA CONTRACTOR S HIRING OR SUBtONYRACTINO 6gNATuRE CERTIF cs <br /> THE FOLLOWING 1 CCRTFY THAT IN THE PERF-0RMANCE OF THE WORK FOR WHICH THIS PERMIT IB le$UEO I SMALL EMPLOY PERSONS SUBJECT TO WON""6 COMPENSATION LAW%OF <br /> CALIFORNIA_—TW APPl1C ANT MUST CALL"NOW IN ADVANCE POR ALL RSGURLED INSFYCTIONS AT 120114.@S 422 COMPLETE DI AMANG AT LOWER AREA PROVIDED <br /> e.e6--1X / /T " L. .. rN.�; ' D.I. <br /> ROT PLAN IO—L.I.r.I Sv.I v <br /> 1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOINO THE PRCffERTY 4 LOCATION OF HOUBE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> OUr UNE OF THE PROPERTY BMW DIMENSIONS AND NORTH MRECTION EXPAMIION OF 6EWADE DIGPOBAL%YSTEM% <br /> D DIMENSIONED OUTLIF/F6 AND LOCATION OF ALL EXISTING AND PRTPOKC, S LOCATION OF IYE116 WITHIN AAOIUS OF ONE HUNDRED FIFTY FT <br /> STRUCTURES INCLUDING COVERED AREAS SUCH AS PATIOS ONVEWAYS AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY <br /> 1I �� <br /> l <br /> I GEPAIITMFMT USE ONLY <br /> [.....r r.n..tr.BY w D I Pyne I-'l bT D.I <br /> 6T D,. <br /> AC{OLINTING ONLY A-I FACT <br /> PF COON] FR INFO AMOUNT ROMITTED CMCIIICA.m RECDYED f Y DATE PP*FItME RVICE REOUE$T MUIMNER IWO*= <br /> 7coo�l <br /> l/ <br /> € f <br />