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APPLICATION FOR WEMPUMP PERMIT <br /> -10 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OMSION <br /> P.O.ROX 3K 304 EAST WEBER AVENUE,STOCMN,CA 95201.988 <br /> (2091469-3428 <br /> NON-PtFUNDASLE PEWT EXPIRES LTEAR FROM DATE ISSUED <br /> pCwM$et*IN Tr+Sp1!) <br /> AFFIICAi10N M HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AHOIOR W6TALL THE WORK.DEeCFMFO.THIS APPUCA760M 18 MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COIARY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBALTH S.(S.ENVMNNREWAL HEALTH DMSION- <br /> lM//�/�� NI <br /> JOB AOGPIESSJ2lor Cry, PARCEL/RIVAFWP Q Fog ONMER'8 MARE , ADDRESS yl,t NI / PF:01�a�[7 3�C^` ! og K7n <br /> CONTRACTOR At 1 ADDRESS <br /> SUS CONTRACTOR ��PI{{ ADORER Loco—_LIC/ PHONE <br /> PE / <br /> TYOF LUPUMP: VCAJEW WELL ❑PEPLACEMEM WELL ❑mow ORING WELL! ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CN088-CONNECT REPAIR ❑VAPOR EXT'/ACTION WELL! ,/ <br /> ❑P+..Y❑11Rrlr H.P. DEPTH PUMP GET FT. / f WAIF-R LEVEL O <br /> (TYPE OF PUMPI ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL/ SOIL 8..- : 8 <br /> ❑DESTRUCTION: x <br /> YPB Of CO ifON! IRCATIO A <br /> 13 INDUSTRIAL ��❑•OP�EN BOTTOM DIA,OF WELL EXCAVATION Ti IA.OF CONDUCTOR CASINO 0.0 <br /> �MFSTCIP/EVATE ,,��`J RAVEL PACK/SUE TYPE OF CASRIG/lTEEUPVC CIA.OF WFU CASINO DO <br /> ❑PUeLXfMUI CWAL ❑DRIVEN DEPTH OF GROUT SEAL <br /> SPECIFCATION R <br /> O <br /> ❑1MMGATION/AG 11 OTHER GROUT SELL INSTALE &ace//J! OROR MVWD NAME E <br /> �AP O P <br /> APPROX.DEPTH E43Yr ON. CONCRETE PEDEY7K 8LLD ❑YrtpyN. 3 <br /> CC <br /> LOCKWO CHESTER @OXMTOVE PIPE S` <br /> 7 - - 3 <br /> PROPOSED COMMUCTIDPIIMWNO MCTNOD-MUD ROTARY AIR ROTARY AUGER CABLE OTTER <br /> Q <br /> 1 HEAEIY CERTIFY THAT I NAVE PREPARED THM APRJCATION AND THAT THE WORI(WILL BE DONE IN ACCOADAWE MATH SAN JOAOUINN COUNTY ORIXNANC!B.STATE LAWS.AND MITES ANOYU <br /> REOULAT1ONS OF THE BAN JOAOUN COUNTY.HOME OWNER OR UCEY VED AOEW'B SIONAT7RRE CERTwKs THE POLLONANO:'I CERTIFY THAT IN THE PFRFORIAANCE OF THE WOPR FOA <br /> TMS PERMIT 19 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORbNAN'e COMING46ATION LAW@ OF CMJFORMIA.' COMRACTOR'8 HIRING ON!US-CONTRACTING SIONATUI E CERTEIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOPP,FOR WHICH TNI!PERMIT IB ISSUED,1 @HALL EMPLOY PERSONS MLLNLT TO SPOPWWAN'!COMPOMATIOR LAWS O <br /> CALIFORNIA.'/ L T11 APPM ANT MOST'CAALLL Xi HOURS IN ADVANCE FOR AL'.IIEOUMIm INSPiCTD AT 120! <br /> ,.. 1 404-3,12S.CO&WLETE DRAWING AT LOWER AREA PROVIDED'. <br /> w/ e X [Z C L V\,EINY(�fTIV. p�y�O�G •�� <br /> PLOT RAN(P.W I.Srin1 Sed. is <br /> U. NAMES OF STREETS OR ROADS NEA7EBT TO ON BOUNCING THE PFOPEJRY. C LOCATION OF HOUSE SEWAGE D18PO@M SYSTEM OR RVI`OBEO <br /> ]. <br /> OUTLINE OF THE RROPERTY,OMNO DIMENSIONS AND NORTH DIRECTION. EXPANIMN OF SEWAGE DWORAL SYSTEMS. <br /> 3.DMENSIONM OUTUNF8 AND LOCATION OF AL1.EXISTING AND PFlOPO.EO S. LOCATION OF MILL,!WITHIN RADIUS OF OPE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUUM COVERED MEAS SUCH At PATIOS,DRIVEWAYS.AND WALA8. ON THE PROPERTY ON ADJOIMNO PROPERTY_ <br /> i ... .. AAAA... <br /> �L <br /> : <br /> = kms <br /> AAAA. AAAA _.•. Y .. <br /> ;RI .• rrl <br /> : .. <br /> AAAA ... <br /> DFPARTMERT USE ONLY -�/f��{X./ <br /> AW.Wc A­1"Sy_�/11 Arr <br /> O.e,A NwPe 0—BY �i��—O/1]J1�1M�.�/�ILQ , Od. <br /> ortl—kn l—tien BY L <br /> C­'.: 7r✓044 „� I No CA')Ivr111 S <br /> ov� ` tgI5 ewo '-4- J jo Grrd fi ol1 n+ { e c✓Vhr w It}. <br /> ACCOUNTINO ONLr_ Al- FACE <br /> PC CODES FEE INFO ANOUMT REMITTED CHECXrICASH NWRVEO BY DAT! P9E.E T1S6,NCE RE E11 IRNOCB <br /> MI <br /> 431a� llo 119/0.00 l I s o 03-as <br /> AL <br /> So 5o -oo (a1 s "21079 o�a8 <br />