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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION ;r <br /> P 0 BOX 388,446 N.SAN JOA0u1N ST,STOCKTON.CA 36201.396 <br /> (203)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRE!t YEAR FAOM DATE ItRNFO, <br /> Mempl[te In TrlpR q*) :i I <br /> APPLICATION in HERE BY MME TO THE LIN JOAtAM COUNTY FOR A PEJMi T TO CONETRUCT ANDA MWALL TILE WORK OEE NI&TML APFILCATION 18 NAGE N COMRIANC[WITH SAN <br /> JOAOUNi COUNTY DEVLLOPEIEMr TML CHAPTERS-1115.3 ANO THE STANDARDS of SAN JOAam COUNTY RIBUC'HLAtTH swkV cEB.ENVIRONMENTAL HEALTH ORAEION. <br /> ,o,J,omu,,,,A,,,, 1603 South B Street crtr Stockton M PAM&&MAPF„ <br /> *w J,.LNAW CA Department of Transportation Ao.. 1976 Charter Way P„DP,6,209-948-7873 <br /> f <br /> CONTRACTOR Geocon Environmental Consultants „tea 3235 Sunrise Blvd Lr, P,,,,1,916-852-4118 <br /> 1 LuecwTRAcroR -`• rJ T IIA2.w4-'r MDRELLPO Box 1664 W.11:Sac Lr,.SS� 11I�,w,916-373-1118 <br /> 1 <br /> TYPE DF WELwuMP: (I NEWWELL ❑RE3PLwttAIENr WELL ❑LnPLraPwlawru r '# ❑DTIIUL <br /> ❑INSTALLATIOP/ IR WELL SYSTEM WPA1R ❑cmes-coNPIErT N►AIR IL ❑VAPOR EIITMCTION WM& VW-1 J <br /> 130—l7 R•OW HP. be"raw BETFT. IS '�NlST WATER LEM <br /> RPE O <br /> YOf PUMH ❑OWOFKRV CE WELL ❑Gwrw'NCAL WELL L ❑ LOl BONNG a <br /> ❑aLSTRIICTIOPk <br /> IHrDJOER u11 FCONSTRUC <br /> A <br /> ❑ LL <br /> ❑BawsTNN OBOTTOM DIA OF iUL OP CoND=OM1 CAWCN/A _ <br /> O <br /> ❑DOMESTEMR1VAATE ❑GMVEL PADUSM#3 Mon- TYPE GP CMOtl,[T[V-IOW PVC iL 0BUL OF WELL CASING 411 O <br /> } ❑PUSUCIIAUMCwAL ❑ONVW tefy sane OEPTN of aROur am 15, :, > CIFiCAnON A <br /> j ❑PmATIOWAG VioTHEA anour ELN emPALED BY WeSteX i 1 ON]UI BRAND NAME <br /> a <br /> '4 NDMfoNN4 GROUTLLALKWFEM1l Y.. ON. 1'i, Cpoacwi PEDESTALLYDnuox:0Yr One a <br /> APPROX.OEPTN I toCK04 CHESTEM BORALI'OVE PPE <br /> S <br /> PROPO+W ODNSTNWCTIOXAVALMG METHOD:MUD ROTARY A+M1 MTABRT nIMEEII X CARL �OTHE�_ <br /> .I �p <br /> 1 HEREBY CEKMTHAT 1 NAVE PINPAMEO TMS APPLICATION AND THAT THE YMW VIAL SE DONE N ACCWMANCE WITH SAN JOADLAH COMSSTYOPONANCEB.STATE LAWS.APm N1LaS AHO <br /> REGULATIONS OF 711E LAN JDAOUNI DOWN.NOW OMSIER OR UBN <br /> CFHSED AOFNT7 GATIME CEPIIRIEL THE fOLLO%VWXL I CERTIFY THAT N THE PERFOR1AANa OF INC MUNI Pon MRSCH <br /> TMS PEEWIT 1L ISSUED.I SHALL NOT ENROV PVWOW SUBACTTO WOREMAWO LOYPO/SATMlN LAVA Of CALIFOPRNA.'CONTIVICTDR'L INiL10 OR S17trCOHfMCTNO SIGNATURE CEMIFLEB <br /> THE FOLLOWING: •I C FY THAT N THE PFMPoEN,ANCE OF THE WON[POLI MRLCH TM fEPSAfT IS 1S&AO.I SHALL N'tOY PERSONS SUBJECT TO WORotAMY COM1POIGATION LAWS OF <br /> 1 CMII-0RMA• CAM UL�T//Cf/y,y"NU/7 <br /> LI IR1L N ANCE POLI ALL REOVAND 3 TIDINI 7 IELSI 4Mi4a�.C]OIBLETL,OIM AT tOY1ER Al1EA PROS ,,T <br /> Ng • TAW t rt �O� ;I� ,ON — <br /> ' 'q .I •� ' <br /> i !.NAVES OF ifREETf OR 71OAOS NEAREST <br /> RAN KW—u SOWS SOWESr TO OR BOUND"TW PROPERTY. a:LOCATION HPYSE SEWAGE DISPOSALPro <br /> LrarLM OM1 wsm <br /> 2.OUTLINE OF THE PROPERTY,DIVING ONAVI MONS AND NORM DOWCTIOPL ij EMPANSION OF SCAY41 DISPOSAL SYSTEMS. ' <br /> 3.ONAENOKWID OUTLINES AND LOCAMN Of ALL EMOTING AND PROPOSED S;IOCATIOH OF WELLS WRHEI MORN OF ONE HUNDRED FIFTY M. <br /> WRACTURM NCLUCKNO COVERED AREAS SUCH AS PATIOS,DPSVLWAYS,AND WALKSS, 11 ON THE PROPERTY OR AOJOMM PROPERTY. , <br /> See attached'sf tq map. <br /> Fns. r.U�.. ... . .. .... . . <br /> '. <br /> prz m s R` VISEV TO.. AEFLecGt <br /> I <br /> { <br /> 4✓�ST....i//4?r�.r,4 .' <br /> i <br /> ...... . <br /> : <br /> { . .... . <br /> .. <br /> . .......... <br /> : : .. _ :... <br /> ........ <br /> IL <br /> - DEPARTMENT INE ONLY <br /> I�Y Appb N A—FWd BY — -- ' n... K"•1� X147 W� 7C7�/ <br /> oras RRPreEm BT Ow Awl R.P-s-BP I i` DN. <br /> 0-0-0.k. We By J <br /> ff' Da. <br /> ca.�...:__�J►'t PDv- e 1.Thi C.t\o,-\ u-kq(Ls _ <br /> P <br /> li ACCOINTINO ONLY: AIRF PACO <br /> Pr CODES PES WA•O ANOINT RRWTTED CHEC11fICA,N RECOVED LY OAF[ POMNTIS944CE RLGUE T NVAOMI 1MVOICE <br /> 5vI GD ' L <br /> 1 <br /> ' .a j <br />