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10-21-1998 2:35PM FROf P- 4 <br /> APPILiCATIOR FOR-?f UIPUMP'PERMR <br /> SAR JOADUIN COUNTY PU13LIC HEALTH SERVICES PAYMENT <br /> ENVIROW:NTAL HEALTH VOISION �C EIVED <br /> W4 EAST WEBER AVEME 5TCaIcM. Ck 261998 <br /> c2os) as&mo r--A Pwar <br /> SAN JOAQUIN COUNTY <br /> 11181S-REFUROA11LE PERM -- ENVIgO PUBLIC <br /> HEA HEALTH CE-FDIV, df <br /> - -) <br /> APPLICATION IS INS BY MADE TO THE GAN JOAOUIN COUNTY ADR A PEiMU TO CONSTRUCT ANDtOR INSTALL THE WORK DEQCAm0E0.'TICS APPLICATION IS MAZE IN COMPLIANCE WRH BAN <br /> JOAOUW COUNTY DZVEI,OPMEM TITLE.CHAPTER 8.1115.3 AND T1-4EE_STANDARDS OF SAN JOAOUNN COUNTY PUmx HEALTH SERVICES.ENVIRONMENTAL HEALTH DMBtpN. <br /> JOS ADO pR APNO 470 N �=Ni "I / ,,/ lw, PARCEL S=AIH. <br /> OWNER'S NAAM nn ADDREOB 5}-S W.�L �t. //u,�Fo b ,�GL PHONE I J-1'o q-so 3)Q <br /> c0IfftlUCroh [Jnu OS' �ilyi�(�nMf;fgl G� _ AD� I537A��e -adv C,..Roseucr Dole PHONE,"//�7jr19oST <br /> ws eoNtTIACTOR /l.I.�J,G�.n�- AZOFESS Ltcr PHONE• <br /> TYVE OF WElLlPINMP: 0 New—Ea ❑❑ BHT WIIL 33 mowromm WELL, ❑ OTNIR <br /> ❑ INSTALLATION Q WELL NIf EM f»AIR D cpovc4xwm!vrrmvm ❑ VAPOR ExrmcTIDN wa.L P J <br /> D Np..D Rn.k N.P. DEPTH PUMP EET FT. RAST WATER LEVEL 0 <br /> TrYPE of PLNa<RP} <br /> Cl OUr4*.vxRvm wmm ❑ oC'oFHymmAt WELL r ❑ So:L norms �( p <br /> BEST.— <br /> NtTETIOm T-�r►E COKSTAUC7ION iFfi:- 1CATOMa A <br /> M /NDUSTRlAL Q OPEN oOT rom DIA.OF WELL EXrAVATION DIA.OF CONOU=R CASING O <br /> J boort?TICC pw^TE Q GRAVEL PACK.mmE TYPE OF CASINOI& OMA.,V OIA.OF WELL CAVING D <br /> PUmi1C/MUNICPAL ❑bmVEN DEPTH OF GROUT WALE AMCIFICATION R <br /> P'WMATONMO D OTHER GROUT SEAL UWALLED BY GROUT BRAND NAME F <br /> moNRomNO ONK.UT sFAL MNMPED- ❑V« D N. CONCRVIE PEDESTAL Dr DNNR1fR[3v. ❑W S <br /> kMRDx-norm Loaclr•o cNE ari R Box►srovE PIPE S <br /> PROVOSM 1METHADI IAUD ROTARY AIR FZTARY AtN)ER CARO_OTHER <br /> NEWEBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THP WORK WILL DE DONE IN ACCORDANCE WITH SAN JOACIM COUNTY ORDMANCEY,VrATE LAWS.AND RULES AND <br /> TWULATXM OF THE SAN JOAOIRH COUNTY. HOME OWNER OR LICENRD A00fr'9 SIONATURE CERTMIt THE FOLLOWINO:'r CERTIFY THAT IN THE POMORMAHCE OF THE WORX POR WHICH <br /> THIS K-MOT 0 MOVED,1(HALL NOT EMPLOY PERSONS SUBJECT TO WOe>LOAM'&COMPDO"I W LAWS OF CALIFON%&- CONTRACTOR'S"IRINO OR SUDCONTRACTIN I WONATURE CEhTI1Ea <br /> YHE FOLLOWING: '1 CERTIFY THAT IN THE FORFORMANCE OF THE V40M FOR WWCH THII PUPIMM IS MOVEN,1 RNALL EMPLOY PERSONS CUSJECT TO WORK MAN'a COMPMOATION LAWS OF <br /> :ALIPOIWIA-' TH-E/AaPIJN:AffT NR CALL G#NOtRW R ADVANCE POR ALL IM IIfPEfiT10Ns ATCM)4�L72, O�ETE DIUINRNO AT LOWER AREA PROVIDED_ GJ <br /> horad X— TI. <br /> MAT PLAN CC~m Sad.f Sq-1 '11,_ <br /> I. NACRES OP STREETS OR RDAbS NEAREST TO OR 1OUN00 0 THE PROPmTY_ 4, LOCATION OP HOUCE SEWAGE DISPOSAL SYSTEM OR PhOPORM <br /> Z. OUTLDNE OF THE PROFEWY.GIVING DbEENSION&AND NORTH O1PEC'nON. EXPARMN Of SEWAfA OMMOSAL VYDTEMS. <br /> 1. DIMENSIONED OUTLINF,s AND LOCATION OV ALL EXMTING AND PROPOSED 6, LOCATION OP vAmis MRrMN KADIUV OF ONE HVNOREO FIFTY FT: <br /> STm• <br /> 'I ffil.INCLl)OING COVERSA AREA&SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE VADIFENTY OR ADJ0004 PROPERTY. <br /> i - - -- --- - - .: .. <br /> ....... .................. ...... MAP ON BACK <br /> ...... ...... <br /> .......... <br /> . ... ...... ...... <br /> ................... <br /> ................ <br /> DIWAKFMeNT UNLE ONLY <br /> AeeII.+NMn A•a.pl.s or O.I. 1�/ CJ 1 A. <br /> tmA kwp..Nmr 0T Daft <br /> FVmp bwm7smr Dr <br /> 9 ' q D.t. <br /> 1..Inrntlen In•a.oa.n Br ,__��J n.0 1, ' <br /> :arnnren[.: <br /> ACCDUlNTM*ONLY: AID, FACT <br /> PB CODES In fhTo AMOUNT/¢6uRTT® ONECKPICASH f wmvEp BY DATE P9om)mERVICF PST muwam INVOICE <br /> 0 0 I l a 0 L '7 1 3 <br />