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APPLICATION FOR WELLIPUMP 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 /> RO(}REIURDADLE PERM11 EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICENPISIS M Til'Ik.bl <br /> APPLICATION IS/ERE/Y MADE TO TNS MN JOAQUIN COUNTY FOR A PER TART I CONSTRUCT AND/OR INSTAL(THE WORT(DESCRIBED.THIS APPLICATION 1.MADE M COMPWJKE WH It SAN <br /> JOAOUIN COUNTY DEMOPMENT TITLE,CHAPTER 9-./1115.7 AND THE STANDARDS OF SAN JOAOUM COUNTY PUBLIC HI M.THIFKV CES,ENVIRONMENTAL HEALTH UMSIION. <br /> D11EWlM1 <br /> JOS ADAPNS -7-75-2,6- /T/I f✓n CTTY )-1 ,/1 - JG PA/IIJC EL EIZ/E(//APN►^"`p/� �r <br /> OWNER•/HAA*_ AIMLESS •U. gOw 7//// T/r"d C(f (��,qON[, <br /> CONTRACTOR_ T—'p uh7D .S'•/i'N!l�,i AooPEel ��i09 li., ?�//n''nG,ie/ i1C. ss-, E •��/10 <br /> SUN CONTRACTOR ADDRESS �/•dD 7.5J� LR,' PHONE. <br /> T <br /> T-y8 DP w[u/PMr: ❑MSW WELL ❑REPLACEMENT WELL ❑MOMTONNO WELL F ❑OTHER <br /> ❑INFTALLATIOM ❑WELL OYSTFTA MPAIA ❑CNOSRCONNECT REPAIR ❑VAPOR EXTRACTION WELL S <br /> S ab 13 It-0 P—h M.P. -9 DEPTH PIN.IP WT & OFT- MIT WATER LSVcL_ O <br /> (TYPE OF PUMPS <br /> ❑OUT.OESERVICE WELL ❑UEOMYSICAL WELL f ❑ EOR.BOAYJ S <br /> ❑mnnuCTDN• <br /> INTER EO� MEM ZONAthucTiom SPECFICATION& A <br /> ❑INgIXTNAL ❑OPEN BOFTOAT DIA,OF WELL EXCAVATION DIA.OP COFIOI/CTOK CASINO O <br /> ❑DOMEST)CA#VATE ❑ORAVET PAMM72E TYPE OF CASINGMTFUJPVC DIA-DF WELL CASINO D <br /> d PUBLR:RAINACIPAL ❑ONVEN DEPTH OF OROUT SEAL MECInc.ATRON R <br /> ❑I ISOATO WAO [101"" GROUT RAL INSTALLED BY GROAT BRAND NAAAE E <br /> ❑MOtayonm OROVT SEAL M WED:❑Y. [IN. CONCREEE PEDESTAL11Y DI%LEIL❑Y- CIN. <br /> a <br /> APnOX-DIFTH LOCXINO CHESTER 90X/STOVE IPE__ f <br /> PRO►Otm COSTRUCTORRMRLIMO METHOD:MUO ROTAX%' AIR ROTARY AUGER CABLE OTHER, <br /> 1 IESENY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANO THAT 7HE YMW WkL 1E DONE IN ACCORDANCE VMN SAN JOAOM COUNTY ORDINANCES.STATE LAWS,AND RULES ANO <br /> REOULAMNS OR THE SAN JOAOLRH COUNTY.HOME OVVNER OR MFNK40 AOENT'/SIONATUIIE CERTFIES THE FOLLOVJRNO!'I CERTIFY THAT IN THE PETFORMAICE OF 111E WOM FOR VMSCN <br /> THIS PEMAT to ISSUED,I HHALL NOT EMPLOY PERSONS OUSAECT TO WORIMAN'S COMPENSATION LAWS OF CALJFOPMA.'CONTRACTOR'S HINNO OR SUB COMMCWHO MONATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK POR MANCH IMM PFRMR 1/ISSUED,1 SMALL EAELOY PERSONS K"CT TO WORKMAN`*COMPBISARON LAWS OF <br /> CALIFORNIA.- TMSA ANT Mi/I CALL 24 HOURS M ADVANCE SF <br /> POR ALL REOUSIED INSPECTIONS AT 7]@014410.2EIS,COLIM DRAWING AT LOWER AREA"M VIDED. J <br /> OW-4 X�TI///1�J L.(ci /�A��J _TIS. I L� DM. �r�O �d ✓�1 <br /> PLOT PAN D.,,.1.Ik"S.r. •1. J <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR NRTVE SOUHUG THE PROPERTY. !.LOCATION OF HOSEWAGE DISPOSAL SYSFEIA OR PROPOSED �. <br /> 2. OUTLINE OF TILE PROPERTY,OIVEIO bOMNSIONI AND NORTH DSECTON. EWPASMON Of SEWAGE DISPOSAL SYSTEMS. <br /> !.b"NODNED OUTLINES AND LOCATION OF ALL EXISTING AND FROPDWO S.LOCATION OF MILLS VYTTRN RADIUS OF ONE MINDED FIFTY FT. <br /> ETIOCTLNES.INCLUDING COVERED AREAS SUCH Al PATIOS,DRIVEWAYS.AND WAAXS. ON TELE OR ADJOINING PROPER", �. <br /> . ......... .....L...'SSSS'. .: .. SSSS...i .. .. ... <br /> : ( <br /> : <br /> SSSS.:. .,._ ...............�..._', ... .. s r <br /> rn <br /> �.. ... •... .. :.. : . ... �. � . SSSS <br /> 'SSSS i...:.... .. .. k <br /> .. . : .: � •...•. . SSSS , . ' .:... <br /> SSSS. .;... <br /> SSSS . . ,SSSS .: . SSSS <br /> .. . :...... . ............... < ... SSSS <br /> EN'S'' <br /> FEB M1998 <br /> i. 1 J�U�:1:'.<1LNQTY <br /> ,+WLTH SEflWCES ' <br /> i <br /> DEPARTMENT UNIX ONLY 7 <br /> APpfMIRI ASS.EI.S SF <br /> Gr.u1NS.SMM D, Ow P.n,b­-1— <br /> DennwlNA SNp wI A <br /> ACCO VNTUIOONLT: AAA FRCP <br /> PF COOFE FEE SEO AMOUNT REMITTED CHECk NH RECFr."2 DATE IIIVOICP. <br /> a L� <br /> Pvb.Health Serv.-EnviFo.173(1/97) <br />