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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.SOX 988,304 EAST WESER AVENUE,STOCKTON,CA 95201388 <br /> (209)451.3420 <br /> MGM•#EFUIEOAILE PERMIT MIMI 1 TEAll FROM 047E 11"tV <br /> MempbRR 4 TPlprint I <br /> APPLICATION M HERE BY MADE TO THE SAN JOADUIN COUNTY FOR A PEPSRFT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCIMED.THIS APPMATKM If MADE N CCMPUAHCE MRN SAN <br /> JOAMN COU'RY DEVELOPMDWTT�T 01116.3 AND THE ST DARDS OF RAN JOAOM COUNTT+Y PUBLIC HEALTH SERVICES,ENVMDNk*NTAL"MTN DryNNON. <br /> JOS AOOPEN.OR APNE/y /1{�[J Wa-fe/�� f1 C._��/?�y71(" �/I^r [�J2CMAP4 �+ �y �) <br /> OMRl/1't NAME jj Er jau/k- /�y rl6 ADOREM / nO��1'EA^y 16V 2 y11 w,4{V 12 1, MONC,J-115/-2967 <br /> CORR/LAC1011_C�F[JFt. fIJ C u ADDRESS 242—F (I VEL/'C;/A+ LEC.7 7�5��FNON[i 4._ 2,?h <br /> SUIS CONTRACTOR ADDRESS UCI PNM1[i <br /> Pm of b Lm—umr- ❑NEIN%ELL ❑RIP LACEMENT WELL ❑MONITORING WELL i ❑OTHEIL— <br /> ❑NSTAUATPON ❑WELL SYSTEM IIEPNR ❑CROSS{OHHECT REPAIR ❑VAr011 vrmACTION WELL P J <br /> ❑N.I.O Mwil H.P. DEPTH PUMP WT_FT. FIRST WATYR LEM d <br /> RYPE OF PIMP <br /> T� e M ❑OVT4)F-WW.4C[WELL ❑OEoPNYWAL WRLL./ ❑ ROIL SIOISNO t <br /> LYOESTISUCTION: g' !3 �" 1-1LL_ A? /re" vv Pop �i A t_ CAtjo ,t _no'geguo- <br /> Iftlotow VOR typil 9P WELL TIO <br /> ❑NOUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EKCAVADON CAA.OF CONDUCTOR CASINO <br /> O DOMESTICAISVATE ❑GRAVEL PACKMW_ TYPE OF CAOHORTE LIPVC DU.OF WFLL CASINO 0 <br /> ❑PMUCAIUNICAAL ❑ VEN DRDEPTH OF GROUT REAL SPECIFICATION RX: <br /> ❑NrSOATIIPUAG ❑oTH[R GROUT SEAL NSTALLED BY _ Grow BRAW HAM[ <br /> ❑Mowrorma GROUT SEAL PULMED:O Yw ❑H. CONCRrTE PEDESTAL r DIRlLOE O Y- ON. <br /> APFIIOK.DEPTH LOCIING CHESTER ROKPErOVE PIPE <br /> PROPOSM CONGrAt CTI1N:O1M1/N0 LIETH00:MUD NOTARY` AM ROTARY AUWR__CAPIL OTN!•I <br /> 1 HE4fY CDLTFY THAT 1 HAVE PREPARED THIS ArPUCATION ANO THAT THE WOFEL WILL RE DON[N ACCORDANCE WITH SAN JOAOUN COUNTY OI DWANC(S.RATE LAMES,AND RU.[S <br /> f REGULATIONS OF THE SAN JOAOUN COUNT V. NOW 0~14 OR LICB49M AOFNf't•*NATURE CERT/ES THE I OLLOW IN0:'I CFIRIY THAT N THE rEIEORMANCE OF TH[WORK FOR <br /> THS PERMIT IS RUED�lmmelY PERSONS SUBJECT TO WORRMAN'S COLM ILAT1GN LAWS OF CAIJPOINA•CorfTRACTOR•S NMNO ON NA-CONTRACTNG SIGNATURE CE <br /> Tl!FOLLOWNW�TTIII WORSI FOR W111CN TNM IS ISSUEDI SHALL EMROY PUSOIM SUSJfCTTO WOPROIAN'l I:OMFVNATPDIRTHErAlIllONNA.' MC■FOR, RfIXISIRD llOFq 11DO yb ]� MAq AT'TO WOARE <br /> EA r110Vf)!D. <br /> ti Y <br /> ROT PLAN POI...to Sal.•)5..1. <br /> 1. NAMES OF STRM70 OR ROADS FIAPENT TO OR ROUNOINO THE PROPERTY. •.LOCATION OF HOUR SEWAOE DISPOSAL fYSTRI OR PROPOSED <br /> 7.OUTLINE OF TK P/IOF[PIIY,SPVMG DWAINSIONG AMD NORTH DNECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> �. DNQNSIONED OUTLW*AND LOCATION OF ALL EXISTING AHD"WMSFO S. LOCATION OF WRLA WRTHN IIADIUS OF ON[HUNDRED FIFTY FT. <br /> 6i1R1CTUEt,INCLUDING COVERED MEAS SUCH At PATIOS.DRIVEWAYS,MQ WALKS. ON THE PROPERTY OR ADJOINING PSOFIERY. <br /> : I <br /> i : <br /> i i.... <br /> :. .... i....... ... .. .... ........ n. ..r.. - <br /> .. «...n...... :....:. .....• <br /> j <br /> 'PAY <br /> 4"•i � <br /> - <br /> : IL. MEN <br /> IF <br /> .dUAdUiTu CCiUNTI <br /> PUBLIC HEALTH SERVICES 1 <br /> ENVLRQNh! T <br /> DEPARTMENT USE ONLY <br /> A-IN~A~.R W d <br /> D.L. A.SP <br /> G—L. o� Pr_ OM. Pie YrP.als..BY DEPS <br /> D.huelbn I�RIn a <br /> ACC.IA.ONLY: NOF FACT <br /> K CODES "N"NFO AMOINFT RNOPTTEO C N:ASN Pwgvro SY DAT! PE"TftU1Y1CI RROUBIT NUMER IMVOIC! <br /> iZo 0 v,�96 <br /> 03/l5'0 <br />