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APPLICATION FOR WELQPUMP PERI._+.} <br /> r SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCK.TON, CA 95202 <br /> (209) 488-3420 py <br /> MI}M-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER puup <br /> I <br /> AP 1tCATION IR IIfnE BY MADE 10 TIIE SAPI JOAQUIN COUtitYFOR A PERMtr to CONS II VCTAN"Ion IN@fAEL 111E WORK OfECnIBEU.TIBS AMICA1ION IS MADE IN COMIMANCE WIIIt SAN <br /> JOAOUP11 COUNTY OEVELOFMfNt Tilt F.CI{APlfn 9-1116.3 AND 111E STANDARDS OF B N J0AoUIN COUNtYPUBLIC IIFAL111 SEn"CES,ENVIRONMENTAL IIEALT If DIVISION- <br /> JOS AUURESS/OR APNI - <br /> } CITV C ,�� PAnCEL B1ZElArIIf <br /> OWNER'S NAME / ^7^ <br /> L.— t'IIOHE I <br /> CONTRACTOR AbbnE RB <br /> T^'} tic. Q IY TONE I�I'�` -s�-�� <br /> RUB CONT MCTgRk1 <br /> AbDRE68 <br /> LICEP'1 LONE <br /> TYPE OFA WEIL"Mr: ❑ NEW wELL ❑ REPLSCEmr"T WELL ❑ MONN OnINO WELL I ❑ OTIIER <br /> l� <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIn ❑ CnOBS-CONNECt nimn El VAPOR EKTPUVC TION WEIL <br /> , HYrE OF MIMPI <br /> •�Y. r 11NN. RepNt N.P. �r UEPI11 PUMP SEt C <br /> FIRST WAIEn LEVEL O <br /> ❑ out-or-SEnVICE WELL ❑ OEGPI{YSICAL WELL I ❑ SON.BOn,NO - <br /> B � <br /> ko, <br /> ❑trE STRUC T IDN: � <br /> i <br /> MTENDEO I'm TYPE OF WELL CONSTRUCTION SPECIFICATIONS I <br /> 111NDUAIRIAL ❑OI'ENBOttOMA <br /> UTA.or WEIL EXCAVATIONN <br /> SIA.OF CONDUC Toil CASINO D <br /> D bOMESrtCmci At Ll GRAVEL rACKJSIZE TYPE OF CASINOIBtELU'VC SIA.OF WELL CASINO <br /> O <br /> PLISlIC11AUNlcmn ❑DRIVEN TYPE <br /> OF GROUT SEAL SPECIFICATION <br /> ta R <br /> {RRIGATIGNIAG ❑OTI{ER gnl)UT SEAL INSTALLfO BY (OnO11T BRAND NAME <br /> © MONITortwor t—1 F <br /> Onour SEAL PUMPED: 0 Y. ❑Ne CONCRETE IYUESTAL BY DlULLfR;❑Yeo []"a S <br /> APFRO X-DEPTN !�C� LOCKING CI{ESTER BOXIsIOVE NpE ' <br /> S <br /> PROPO6E(O CONS TRLICTION+ORILl NO MFT/fOOv MUD ROTARY AIR ROTARY AUGEn CABLE <br /> OTHER <br /> I If(914Y CERIIFY MAT T IIAVE PREPARED 11110 APPLICATION AND THAT THE WOPK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY OnnIHANCEB,STATE LAWS,AND MILES ANO <br /> nEntfIATIOM6 OF t1IE SAN JOAQUINCOUNTY. 110ME OWNEn On LICENSED AGENT'S SIONATUnE CERI1r IES THE rOUOWING:'I CEItt IFY 11tAT 1N TIIE FERFOAMANCE OF TIIE WOIK FOR 0 SCH <br /> TIRE PERMII IS I9811ED,1 SIPAI.L Nor EMPLOY PERSONS SUBJECT TO WORKMANY COMPENSATION LAWS OF CALlrORNIA,- CONIRActoR'B 1{{ruN(O OR BtTB"cONiMCi1No SIGNATURE CERHtIEs <br /> T11F ERIIfY TI IAT IN TIIE ORM E OF TIfE WORK FOn W1nCII THIS PERMIT IB 18SUED,I SIIALL EMPLOY FEnSONS SUBJECT TO WORKMAN'S COPAKNIAtlo LAWS OF <br /> I`OOLOW�CALIFOR THEA CANT MUST C 0 t10 !N ADVANCE FOR ALL REOIIIRED{NIPECTIONI AT 12091406-3423. COMMEIE DIIAWING AT LOWEn AREA fmVIVEI). <br /> RID•n 1 A <br /> Tltle <br /> note <br /> MOT PLAN,Dtew to Bade)Sado <br /> 1. "AMER OF RIREE►S On ROADII NEAREST TO On BOUNDImo me morERTY. -to <br /> oUrLME OF THE morf"FY,GIVING DIMENSIONS AND Nonllr 01nECTION. 4. LOCATION OF IJOU#tEWA SEWAGE S SIt SYSTEM On MtrT{g6EO <br /> 9- DII,TFNSt011EO OUTLINES AND LOCATION OF ALL EXISTING AND PnOro BEr/ EXPANSION F SEWAGE OIIIN RADIUS <br /> OF ON, <br /> EL STnl1CTURE8,INCLUDING COVERED AREAS SUCII At PATIOS,DRIVEWAYS.AND WALKS. �• LOCATION OF WELLS Vv1T1lIN Mb1US OF ONE IIUNImEh FIFTY tr. <br /> 0"Tilt lrTY OO ADJOIHINO PROPEnry, <br /> 1199 <br /> . y <br /> f <br /> !Jl•�,.f P 1/br� T� <br /> SII( d <br /> DrrAnt E uIE(ONLY <br />� r 1111 ,o...�•r��..,...;�-.. . a->...� - 1 C/!��"Y 1 7 <br /> -r bel• 1 C J rz i <br />". �. .��-_..... Vim- Me•—.- �� <br /> 0—ul In•paeflw,Sy Sou ilmv h»peallan By <br />,neer <br /> Delo _�4C_ <br /> 0-1-0—Inopwr•Ibn of <br />-A M. Dote <br /> Co.n .0c <br /> 1+Rlaea <br /> y� <br /> ACCOUNIING ONLY. TUU/ <br /> FACT <br /> c T[COOES FEE INFO AMOUNTRFMlT1Eb CIIfcK ICAI11 RECEIVED BY DATE PtlUulllSF71VIcERE0UES1NUM8[TL <br /> O� ( t INVOICE <br /> (�• ✓' I\ <br /> t <br /> Pub,$4dh SeN.•Envh(O.173(1197) <br /> n., , <br />