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1 I <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OIVISION <br /> P 0 BOX 388,446 N.SAN JOAQUIN ST,STOCKTON,CA 86201388 <br /> {208)4MU20 <br /> RQ*REFUNOABLE PERMIT EXPIRES I YEAR FROM OATS ISSUED <br /> IGnfYn IB TFIpi ut* <br /> APRICANVON It WERE M MADE TO THE SM JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTAL THE WORK DESCINPED.TIPS APPLICATION S MADE IN COMPLIANCE WTTH SAN <br /> JOAMIk COUNTY D"LOPMBR TITLE,CHAPTER Y-1115.3 AND THE STAND 8 OF.-JOAQUIN COUNTY PUB C HEALTH SERIN-ENVBIORNREN TAL HEALTH DRVW". <br /> JOB ADDIIEV(POR APH CITYIII PARCEL 6&M1AIM/_ <br /> ONOEIIV NAW ADpES8 RiOIE <br /> CONTWICTOR- is LIC/ OF Z_PHONE/7,7 <br /> AUB CONTRACTOR17,1W_NZ, AGGRESS LIC! PHONE/ <br /> TYPE DP NELLiPIMIP. wEu ❑REPLACEMENT WEU ❑MONITOMNO WELL/ ❑OTHER <br /> .,❑.,.,/ItVALLATION ❑V4t L SSYMM REPAIR ❑CROSSCR ONNECT REPA ❑VAPOR EMMCTIDM WELL I J <br /> YTF�wr�Ryr N.P. �1 DEPTH RASP SET Fr. PRET WATER IEVF 0 <br /> (TYPE WM% <br /> ❑OUT-0FSERVICE HELL ❑GEOPHYSICAL WELL/ ❑ SOK SOUND B <br /> ❑[)EFTRUCTYIN <br /> HY TION LWECFtCATIONs A .f� <br /> ❑1 µ OPEN BOTTOM DIA.OF WELL EXCAVATION DO,OF CONDUCT43A CANW 0 <br /> MFFTICIPPVATE ❑(NAVEL PADAWE TYPE OF CASINOMEELMVC DIA.JF HELL CAANO O <br /> ❑PVBUCflAUNM:Pµ ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑/NNGATIOWAO Q OTHER GROUT SEAL INSTALLED ffY /^ /MOUE BRAND NAME E <br /> 13TN�UO MONRGROUT SEAL PUMPED:PUMPED: Y- yFle CONCRETE FUNFTAL SV OWLLER - ❑No S <br /> APPROX.OFPTH 3 _ LOM MO CHESTER SOXWOW PWE_— + / - 3 <br /> 1110 PON WM ETRUCT1011,ON, METN00: wD FIOT.ARY NR ROTARY AUGER _CAKE ✓ OTHEF , ^ <br /> I HERESY CERTIFY THAT 1 HAV!PRWAPED THIS APPLICATIONAND THAT THE WORK NEL U DOHE IN ACCORDANCE MATH SAN JOAOUN COUNTY ORD*IANCES,REATE IAWS,Alb NAPA AMO V <br /> REDULATIONS OF THE PAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIONATLRE CEKWES THE FOLLOYMO:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> TI*S PERMR IS ISSUED I SHALL NOT EMPLOY P.SUBJECT TO WORIORAM'S COMPF)1*ATION LAWS OF Cµ1FOFNlA'CONTRACTOR"NIPNG OR BUSCONTRACTNG RONATLIIE'CFRTIFEi <br /> TIE FOLLOWIHO: 'I CERTIFY THAT'IT <br /> PPA,ONHANL'E OF THE WORK FOR`ALSCH THIS PUMIT IS ISSUED.I SNA. DAPLOY PERSON*SUBJECT TO MIGIMMAN'S OOAIpDAs11TPON UWB OF <br /> Gµ1FORNA'`IE UCANT NSI <br /> TO E•REMs1 IN ADVANCE I'W ALL PAGWM INN OMS AT 130N Mii Z3.COFIIETE DRAWING AT LONER AREA P ONOED. <br /> Slpr>.R X _T41. DAo. <br /> FLor PUN .RNA y iIAYA .-- <br /> 1.NAMES Of fTRE[TB OR ROADS NEAREST TO OR sO1JNON0 THE PERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYFRM OR F`FWGKD <br /> 2.OUTLINE OF THEPIOPBfrv,OINNO DSEhBgMp/YID NORTH IDN. EKPANs10H Of*SWAG[DISPOSALnRfl110. <br /> 3.OYlNSONED OUTLINE*AND LOCATION OF AL EXISTING AND PROPOSED %-LOCATIDN OF WEILI NTTHN RADIUS OP ONE HUNDMD FWrY FT. <br /> STI1JCTtjR INCLUOINO COVERED AREAS SUCH AS PATIOS,DNVEWAY9,AMI WALKS. ON THE PROPERTY OR AO.ANING PROPERTY. <br /> .. .. <br /> pAY.ME . ... :.. <br /> q.E_CF[VED <br /> JUN: 5 1995 .. ... ...: <br /> . <br /> SAN 4400iN COONTY <br /> PUBLIC HEALTr•8ERVi S <br /> 1 ONMcN A ........:.......... <br /> ENY <br /> OEPARTMIMT USE ONLY <br /> Olart Ynpsfim By / � ` rtp k—Id—By <br /> Dr,u.V—WIPIeOA,.Gy. RAH• <br /> CMNr ; <br /> ACCOUNT ONLY: <br /> M COO SA mi. AMOUNT W". IA(): ASN RIICSVM AY OArp PS"TIA-6-WE R T NINIM61 IMVLRCB <br /> q-:3 in C. qd!q�b <br />