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APPLICATION FOR 1YELLIPUMP PERMIT <br /> ' "SAN JO'�' V COUNTY PUBLIC HEALTH SERVICES' <br /> Erilf,iiI06NMENTAL HEALTH DIVISION <br /> PA,BOX 988,904 EAST WEBER AVENUE,mcKTON,CA 95201388 <br /> (209)460-3420 <br /> EON-REFUNDABLE PERm EXPIRES 1 YEAR FBDM"ATE ISSUE" <br /> APPLICATION 1811rRE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CpNBPgUCT AND/OINSTALL THE WOIK DESCRIBED,TRIS APPLICATION IA MADE IN COMPLIANCE Yvn IM SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER/-9.111 S.3 AND TIfE STANDARDS OF BAN JOAQUIN COUNTY PURUC NEALTI{SERVICES,RS APP ICATI N 0 ADEIrk DIVISION. <br /> JOB AOORE89/0R AWN F, etty 1 11 l`.-'' �E PARCEL BUFJAPN f0-(I <br /> OWNER'S NAME IC �4U T ADDRESS �t Iy yfbTYySY Sty 7-� LjEY�ZOCFyb NER C.6371 <br /> CONT RACTOR � -si�0' �`—.-. ADDRESS 1v{ $} r �I <br /> �. C4046(4 PHONE ICEs <br /> BUB CONTRACTOR AJIDRE68 LICE PHONE 4 <br /> TYRE OF WELLIPVMP: 1--1 NEW WELL ❑AEP1ACFMENT WILL t.J MOPSTORIFIG WELL 4 ❑OTHER <br /> ❑INSTALLATION ❑WELL GYSIEM REPAIR ❑CROSS-CONNECT REPAIR 11VAPOMI.TRACTION WELL I <br /> pPE YOF PUMP ❑N—11Rec.4 H.P.— OEPTN RUMP BET It" FIRST WATER LEVEL p <br /> ❑ORII"Or-BEITME WELL ❑GEOPTYSICAL WELL! L'J Lbq DOTING B <br /> ❑DTBTRUC710N: • - <br /> MENDED 1E YPEOF CONSTRUC IbNiPECIFICA IONS <br /> �U�-II S II A <br /> ItJ ONDUBTlRAL ❑OPEN BOTTOM b1A-OF WELL EXCAVATION , OM.OF CONDUCTOR CA6IHG p <br /> U PuDLICDOMESKASBVArE E❑I O1 1:PAMMI_I TYPE OF CABIHOIBTEEUPVC DIA.OF WELL CAMINO p <br /> ❑PUBLIC BHUNICIPAL - CJ DRIVEN DEPT"OF GROUT SEAL_ {S�,., SPECIFICATION A <br /> Fj❑tMUGA7NINIAO ❑OTHER GROUT SEAL PARIALILM MY Y'r•(I GROUT MRAND NAME E <br /> LJ MOMTOIONG ph GROUT HEAL PUMPED: Yr ❑He CONCRETE PEDESTAL ROLLER:❑Y. <br /> ❑ B <br /> APPROX.D H_ iY.J .'• - tOCKINO CHEATER SOXMTOVE PIPE S <br /> PROPOSED CONSTRUCTIONIVIVIVNO MFTTIOO}MUD ROTARY AM ROTARY AVCEn CAS OT U'Fba <br /> 1 HERESY CERRIFY THAT I HAVE PREPARED TWO APPLICATION AND THAT TIME WOFIK WILL DE DONE M ACCORDANCE WITH SAIL JOAQUIN COUNTY ORDINA Ee,STATE LAWS.A B AHO <br /> 'hEOULATIONS Of THE DAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'D 0014ATUM CER www THE rDLLOWING:'1 CERTIFY THAT IN THE PEAro FOR WIRCH <br /> TMS PERMIT I8 ISBUEb,I SHALL NOT EMPLOY PERSON"HUBJECT TO WORKMAN'S COMPENSATION LAW@ OF CALIFORNIA;CONTRACTOR'S Mn"M OR BUIL-CONTRACTING BTONATURE CERTIFIED <br /> THE FOLLOYANG: 'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FDR WHICH THIS PERMfT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WQIIODBAM'e COMPEIffATTOM LAWS OF <br /> CALIFORNIA.- THE MPUCAN MU�ST�7CAE�L,24 Mount M ADVANCE FOA ALL REOUREO SIB►ECTION%AT 12PBf 441841421.COMPLETE DRAWING AT LOWER AREA P"OVIOED. <br /> z �,-- <br /> Co.. C9 C <br /> PLOT THAN ROPE to ea.f.l Sew •le <br /> 1.NAATEB OF STREETS PR PE TY-06 OM7EAREgT 70 OR AIMO ROUNDING THE PROPERTY. <br /> 4. LOCATION OF HOUSE SEWAGE DIBPODAL BYBTEM OR PIopocEb <br /> !.OI1TlNTE DF THE PROPERTY-ONDIO DAArHBNJH6 ANO NOIITH OIR�CTpN. EXPANSION OF REWAOE OTGPOBAL SYSTEMS. <br /> 2.DIMENSIONED OUTLINES AND LOCATION OF ALL CKI9rrNG AND E{bPOBED B,LOCATION OF WTTLB WITHIN nA,Uq or ONE"UNOREn r{FTY rT. ' <br /> STILUCTI/ID",RTCLtIpNO COVE7Ep AREAS SUCH As PATIOS,DRIVEWAYS,AIA WAIAD. ON THE PROPERTY OR ADJOINING PROpERTY- <br /> ... c.. .:. --...,, ... <br /> IeCtSe : 5ec.... <br /> a �> <br /> ... .a.....:. <br /> :. i.. "a...... . <br /> .. <br /> . <br /> OVM1MENi USE ONLY App"..IINt Aftwt d GY <br /> 0.1. Mar <br /> 0,a k.-0rn DY Drtr h.np Inpare}en By DHa <br /> ow-11..hwprrlbn RY O.I. <br /> Cemmw,e.: <br /> X5.3r s Pr 3't` <br /> ACCOUNTING ONLY: AfDP rAC4 <br /> R COOED FEE INFO OIMT gEM{T7 ED CHECKPICANR RECflVEO BY PATE PIMMITI8ERICE REQUEST M18.Iffm INVOICE <br /> 1 <br /> 1 <br /> Pub,Health Som-Emliro,173(3196) * r <br /> 5V� WT L� •{{ <br />