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APPLICATION FOR WELUPUMP PERMIT <br /> OAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES- - <br /> ENVIRONMENTAL HEALTH DIVISION <br /> *ft4 EAST WEBER AVENUE,STOCKTON,CA 95202"4111111" <br /> (209)468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICampt.t.Ie Tr1pne.t.) <br /> AM IC AT ION IS INRF RY MADE 10 TNF SAN JOAOUIN Co1/NTY fan A PFRMIT 10 CONBTIIUCT ANnIOR INat ALL 1/IE WorK DESCRmEb.MIT APPLICATION NI MADE IN COMPLIANCE INNII 6AN <br /> JOAOUIN COUNI V DEVELOPMENT TITLE.CIMPIE"9-1115.3 AND TIIE BT ANDAM8 OF IIA"JOAOUIN COUNTY PURUC IKALTII I ENV10E8.FNVDIONMENIAL NEALIN 1NVINmN. <br /> � 1R <br /> JOG AOMES.mn N•NE ..�Ll 9 �� ` F CItV -F E'1.' E�� J PARCEL SIZEIAPH8 <br /> OWNfn'aN ME 1 ' 6 r AVOREaB� �,. �� Ll'v �l 2G7• �7 j�- <br /> //,/ yJ� /M�IONE E <br /> C�N t )e AODRE68 1`I I? 1�\T I 'I1C/� O�I_ "KNJE <br /> _a1N1 COMRMCTOR ADOnE88 _ LACI mmNE F <br /> TYPE OF WELtJPUMr: ❑NrW WFtt ❑REPLACEMENT WELL ❑MONIT O."o WEtt E f4 1 ❑O111ER <br /> ❑INSTALLATION ❑WELL eYeT EM REPAIR ❑CROSSCONNECT nEPAm ❑VAPOR EXNUCIION WELL E J <br /> _ ❑N_El n-m, N.P. DEPT I1 PVMr 8ET ...Yr. MOT WATER LEVEL o <br /> R YPE OF PUMP1 <br /> ❑OVT.OF.SERVICE WEtI ❑OEOPLIV8ICAL WELL ❑ BOR RORINO 8 <br /> ,LI.DEST1111CTION' <br /> IN r ENe ED V6E TYPE aF WEL CON6Inuc TION SPECIFICAIION4 <br /> ❑RJel1.I SI AT ❑nrEN"art OM DIA.OF WEIt EXCAVATION DIA.OF CON)UCtOn CAa1Nn O <br /> 1_l OOMFSIICa1XVARE ❑GRAVEL PACK/SIZE TYPE OF CASIN(IMIMIPVC MI GIA.OF WELL CASINO T N O <br /> ❑NIMICAA OMWAL ❑DmVEN OEnll OF GTIOUT 6EA1. STECNICATION " <br /> ❑IRRMAIKYWAG ❑OIIIEn annuT REAL tNSTALIAD 8Y IAN- <br /> "RAND NAME E <br /> 1•mommmNa 7 l GROUT REAL PLUMPED:11Y•• IAN- CONCnETf rEOESIAL 8V DIALLER:❑Vw ®N• S <br /> APPROX.ern N_ LOCKING cUllIffR SOXIaTOVE PIE - 8 <br /> meMNce CONlITRUCTIONRMLUNO METHOD: MIM nOtA"Y AIR IIOTA11Y AUGER CMLF. OTHER <br /> 11_r 1FnV CFRTtrY TttAi 11MVFf MFPAnFO MITI APPLICATION ANn THAT ILK WORK WILL fit DONE IN ACCOnt)ANCE VAIN SAN JOAOUIN COUNTY ORRINANCES.S/AIE IAWR,AND MILFR Apm <br /> OFOIX.ATIONS or Tim SAN JOAOUIN COUNtY.HOME OWNEn On LICEN6fF)ArIMI'S amNATUM CERI1rlEN IIIE roUoWINb:•1 CERTIFY TNAT IN INE rfaTOnMANCE Of TIIE WORK r0"WN1CN <br /> 11RS" MIT IS IeaVEO.1 SIIAI l NOT EMPLOY PER6aN6 8USJECT TO WORKMAN'S COMPENSATION 1AW8 Or CAttrorMA.'COMMCTOn'o t41NNG On RUN CONTRACTING SIGNATURE"rtTDIEN <br /> 111E rotto"No: 'I CERTIry NAT IN 111E PERFORMANCE Of TIIE WORK ran WHICH INN PE�M41T 181SSVED,I NIIALL EMPLOY PEnooNB eUSENS <br /> JECT TO WORKMAN'S COMPATION UB WOF <br /> CALNORNA.- T1/1 PPIICAN MVST CALL t4"OUT16 IN ADVANCE Fan ALL"EGIXREO INSHMNO1NS AT I"In 466.6426.COMPLETE GRAMM AT LOWER AREA PVOV1DEO. <br /> PLOT PLAN 101—1•R•N•1 R•N• 1• <br /> t.NAMITof aIRFEtR On ROADS NEAnFPT 10 On FOUNDING 111E rnOPF.n1Y. 4.LOCATION Of NOVSE SFWAGF m8PO8AL SYMEM On PROPOSED <br /> Z.Ol,Tl1NF Of LITE rnerEnTY.OIVINO DIMFNBION$AND NOMN DIRECTION. EXPA"INON OF SEWAGE DISPOSAL SYNit"41. <br /> :1.DIPAMSK)NEO OUTLN11%AND LOCATION OF ALL EXIRTING ANO PnOrOaF.D S.LOCATION OF WEILS WI NTN MONK OF ONE INRIDM.D rWtY rt. <br /> CTAUCTURER.INCLUDING COVERED AREAS 6UCN AB rAT1O8,DTRVEWAYI,AND WALKS. ON TIIE PROPERTY On ADJOINING PROPERTY. <br /> . .: .. <br /> .. ;. <br /> : <br /> 7.199.8 <br /> P <br /> I. <br /> ! <br /> .. .. .: <br /> D"AA MENT USE ONLY <br /> G,n,4 1,111^.10111"Y D•I• WIPP MF1M11•n of bF1• <br /> Dr,n.1111n t,11r1^11—fly b•1• <br /> �.11111111.. � - ro L u <br /> 1�0� Lir• 1�C .-S c� E c_ • � !, <br /> ACCOVN TING ONLY: NDB fAC6 'S �' Lfrle <br /> Je <br /> 1E CODE. FEE INFO AMOUNT ITEMITIED CHECKI/CA611 RECEIVED RY DATE PDOWT/SERVICE REQUEST NUMSM INVOICE <br /> r 11 © -7 C) <br /> Pub.Health Se".-Enviro.173(1187) <br />