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4. LOCATION Of HOUIE IMAGE 011411151 EYSTEM CM PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />I. LOCATION OF win.. WITHIN RADIUS OF DIVE 101101413 HMI FT. <br />ON THE PNDPERTY OR ADJOINING PROPERTY. <br />Srl) k /re. Rot <br />'PkYtilE.01 . <br />:77r <br />mg .22 1998 <br />SIATst...4.141e4.04 <br />PUBLIC rt=.7tLIP4 SERVICL - <br />ENVVIONopfElITAL <br /> <br />HEALTH r);%AbiON <br />Plat PLAN IlMeN IS leehal Seale <br />I NAMES of STREETS ON ROADS NEAREST 10 DROOL/WINO THE PROPERTY. <br />2 01.115SC "IMF relOPERTY. 5I1,7110 DMJEMEMONS AM NORTH CmarcnoN <br />3 DimfNMONE0 OUTLINES AND LOCATION Of ALL EXIST.] AHD PROPOSED <br />ET RucTUTTED INCLUDINO COVERED AREAS SUCH AS PATIOS, DIVVEWAYS, Mal <br />HE <br />k If <br />e S7c-,z_ <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />MOM-REFUNDABLE PERMIT EXPIRES I YEAR FROM DUE ISSUED <br />Memptele Ii, 1rIpReat.1 <br />APPUCATMN IS IMRE BY SEAM TO THE SAN _MADAN COUNTY FON A PERMIT To coNsTRuCT AllOson INSTALL THE WORE DESCRIBED. Tina APPliCATIONS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY OFFELopMENT TITLE. CHAPTER 9.1116.3 AND THE STANDARDS Of PLAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH <br />IT JOE ADDRESTIFOR APN• C 9e; HIFIr/V—Colert/ 727, PATICR,MF/APNO <br />OWNED. NAME d /tie r,"7"-.3 AormEg. ,26, `/C /j/o,Lre-,- &It <br />CONTRACTOR iv,S tr,) ADCA,F ,M) 1:7•)// ik4JIZIC-2DO /.?_s - TOONE • <br />SUB CONTRACTOPI ANSWER 37 LICH PHONE I <br />TYPE OF WELL/PUMP: 0 NEW WELL 0 ITEPLAcEMENT WELL 0 ANDETTOPIIND writ. S 0 OTHER <br />0 WETALLATION 0 WELL SYSTEM REPAST 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION Wm I , k' '-' <br />C b • 0 Maw 4.1.,,...,1- H P. i 2 _ CIEFGH PUMP 13E1 T. FIRST WATER LEVEL ,94f IT <br />DEPT OF IIMmAp, C . 0 OUT-OFKIDACE WEU. 0 REOPHySICAL WELL' 0 SOIL SOTTIFYJ a-- -•-• <br />0 DESTRUCT-sow <br />INTENDED Oti TYPE OF WELL CONSTRUCTION sPECFicATIONS a , _ <br />0 IMDURTRIAL 0 OPEN ROTTED. CIA. OF WELL EXCAVATION CIA. OF CONOUCTOR CASINO a <br />— . <br />0 DOMES, IC/PmvATE 0 GRAVEL PAcEiligi Iv!'! or CASINO/1TM pvC CIA. Of WELL CASINO o Sli <br />CI pUBLICSAIMICMAIL 0 DRIVEN OFT'TH OF GROUT REAL SPECIFICATION ft <br />0 INNIDATKINIAIII El OTHER GROUT SEAL INET ^UFO By (0101.11 BRAND NAME f "Z\ <br />0 MONITORINO ntIOU1 SEAL PUMPED 0 Am 0 No CONCRETE PEDESTAL BY MUER Dv_ 0w. • --; <br />APPROX. DEPTH <br />....t .... <br />,c...V.-.-. _. <br />I HERESY CERTIFY THAT I HAVE PREPARED 114111 APPUCATION AND THAT THE WORE WILL SE DONE IN ACCORDANCE WITH SAN JoALIGIN COUNTY ORDINANCES. STATE WM.. ANO sul ES ANC ' <br />MOIR ATIONS OF THE SAN JOAOUIN COUNTY. HOW OWNER OM MENGE° AGENTS SIONAT UPS CEITTIFIES THE FOLLOW/4G- 'I CERTIFY THAT IN THE PERFORMANCE Or TIIE WORK 105 +1111015 <br />TIRE PERMIT III ISSUE.. I s'AII NOT EATPLOY PERSONS SUBJECT TO NEGRI:MANS COMPENSATION LAWS of CALIPONSA.' CONTRACTORS HAMM OR 9(111-CONTRAC TOM SIGNATURE CERT/RES <br />THE FOLLOWED) 'I CERTIFY THAT IN THE RENFOINSANCIE OF THE WORK FOR WHICH THIS PLAINT IS ISSUED. I CHAD. EMPLOY PERSONS SUBJECT TO WORXMAN'S COMPENSATION LAWS Of <br />E4LIC CAIDONFINC I ANT MUST CAM, 24 HOME IN ADVANCE 105 AU NEQUINED INSPECTIONS AT 11041 4114421. COMPLETE DRAWING Al LOWER AREA PROVIDED. <br />-../ <br />....1 TIM 0 td/ Xi° /— o.. •3------?e-r--,6;-•:r <br />DEPARTMENT USE ONLY <br />ApilSeaSen Areemleel By <br />Mete Inereeeen <br />0.0,11C1/0,1ragmleNen IT <br />C — <br />c ' <br /> <br />4.1 bete ArEa <br />-Lar T 4.-/_9-,s <br />OEN <br /> <br />LOCKiNo cHESTEN salueTovE PIPE <br />ITIOPOIMM COMSTRUCDOMIDMILLIMD AMMO: IMVO DOT AP MA POT AMY AMOR CASEY <br />/1 L 4 r;;,..: <br />AcCouNTING ONLY <br /> — <br />1 <br />ARM rACS <br />_ <br />PE COOTS TIE INFO AMOUNT REMITTED de AIN 11(01+150 5+ DATE IIINDINTSIERVICE REQUEST NUMSEIL I WOW: <br />Lt 3 7 V ':1-. 5 Q <br />-.4.-- 4.) ;.1.,-,4 c(-5 5/).9m,. • <br />i I . <br />Pub Health Serv - EnvIro. 173 (1 T97)