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APPLICATION FOR WELUPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION QSZbZ 8W4 EAST WEBER AVENUE, STOCKTOR CA�W,'�- NEAi_I f I 80.91 468342D �rd�1�p -• ''i SERVICE D0WREMADABLE PERMIT 7 Ph 1, 27 APPLICATION IS NBC BY MADE TO THE SAM JOAOUIN COUNTY FOR A PERWrTO ClOtMRI=ANDIDR INSTALL THE WORK DEBCRISM.'ilIS APPLICATION R MADE IN COMPLIANCE WITH SAN JOAODUN COUNTY DEVELOPMENT TTTIE.CNAPTER -81115.3 AND THE UrANDAMO Or SAN JOAOUIN COUMUC Y PIBHEALTH MWICEB.ENWONMOUAL HEALTH OMMON. JOS AO RIERINORAP/#�3D3 Pr,l ►L :1VeI,4LtL CRY �oP% PARCEL 027JAPM OwNBt'S NAIWE 1 O .0 4 kG t�l'L C'D ADOPT= o t 5�2 C`�!-'P OHE I i�)77y—Zlilo l T 7S /� , -1 cOMrRAcroR�� (– u`�l ��C ADDRESS�`��' [tr/"c�Ci'pS4L e LIC/ PHONE S/� ISS seem p11ld.L4 AJ clr�c C Ayk I �p . ..`ADp+lEtiB p, t o f S-7710019 P HONE o77q o TYPE OP WELJ.IPUMP: ❑ NEW wm ❑ REPLACBM W WELL D MOR!<TORSHG wELL I ❑ arRER ❑ MWALLATION ❑ vmL vywm REPALR ❑ cwvv xmmEcr P*PAat ❑ vAPOR wan4cnm wELL_r J D N.w❑P.* H-P. OEPIII RUMP SET FT. F0Wr WATER LEVn p " fTVPE OF PUMM I ❑ OSR-0F40rAM WELL /1 ❑ OEORIY/S+tCAL WELL/ D 500.&=M l� B '�DEerRIxrLON:YI'1.�~1 �Y✓L W-^�T �r�l�Dt t 1` G�+UC"�G'rL i� T"t��LJ/AC�ii�cP•s:c::`��,�� ITforti S r•Cr`s�� - � INTENDED USE TYLE DF WE].L CONSTRUCTION iPECv:ICATIOM& - � � A N ❑ PC UBTPPAL ❑OPEN S6TT6M DIA.OF WELL EXCAVATION DIA.Or CONDUCTOR CASINO D ! ❑ DIMEST1UPRVATE ❑�' GRAVEL rACI mn TYPE OF CASMO/LTEB/PVC 1! V L DI/-OF WELL CAST fi D .J C3 PUSUCIMUN=PAL 0 DRIVEN DEPTH OF OIIDVr SEAL »CATIDR x ; E3 MMOATIONIAO EJ OTHER - OROUT SEAL INSTALLED BY OROUT BRAND NAME E fu MDNITOftm - GROW SEAL PIMPED: EJ v« E3NocmcpmTE PEDESTAL BY LBULLER:❑Yn 13m- s /AFPROUL tI�TI+ UICKI IO C KW- BoxlsrovE s PROPOSED I':DMSTItUCTtOMIDI{idIMO METIIOCt MUD RDrARY AIR NOTAW AWER CABLE OTHER J 1 HERESY CERTIFY TWAT 1 HAVE PREPARED THIS APPLICATION AND TMAT THE WORK WILL DE DONE IN ACCD#mANCE WITI1 SAN JOAOUSI COUNTY ORDINANCES.STATE LAWS.AND RULES AND REOULATiOHS Or THE SAN JOAOUM COUNtY. NOME OWNER OR LIC'ENm AOSim EEOMJATURE CERTIFm6THE POLLOwom:'I CERTIFYTFIAT M THE Pf:RFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUM= WORIIM4^WA COMPONSATIORI LAWS OF CALIFDIVAk' CONTRACTORS HIRMD OR BUDCONTRACTINO SUONATUM CE MM$ THE FVUMWMD: '1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WIlIGH TMS 109901"IS ISSUED,I SMALL EMPLOY PER OMS SUEJEcr TO gfOMW"'4 COMPIDISATION LAWS OF CALIF MAA* 3M Ro M ADVANCE FOR ALL RIES OM M4 AT MOS)40S4h4=. COMPLETE UP AWIN I AT LOWER AREA PROIAD Blon.a X TIW 'eG� ct-"n golI s LI.t. lyGQe G4`C[YL�M POT PAN W~to somw Ca"@—L—•te� Cl �lrc1 � 1. NAMES OF f.TRE7TS 611 ROADS NEAREST TO OR SOUNDMO THE P OPOTTY. 4, LOCATION OF HOUSE SEWAOE 09SPOM SYSTEM OR PROPOOM 2. OUTLINE OF THE PROPERTY.amm DIMENSIONS AND NORTH DUIECTIOK EXPANSION OF SEWAGE DISPOSAL SYSTEMS. _ 3. DIMENSIONED OUTLR IM AND LOCATIDH OF ALL EX=MVC AND PROPOSED S. LOCATION OF WELLS WLTIRN RAOMS OF ONE HUNDRED FIFTY FTI. STR UCT'URES.PICLUDING COHERED AREAS SUCH AS PATIOS.DItVEWAYE.AND WALKS. ON THE PROPERTY OR AD.1009M PROPERTY. - - - - ---- r� .. .......... .. . .. Q-: 1998 1 l . , ....... :.... .. :cr rR time COUNT r MAP ON B ,E-A.•"•`-SERVICES E......L.. ................ ...... .. . .......... NVJROMM iglAL HEALTH DIVISION .:... .:............:......w......._._ .............a.............:................-- - _ E, r I t1EPARI7AMr USE ONLY r, Grout Irrrototbn pu"m Inowetlon Dr.rn�tlen Ie�prolion BT � D.t.� 2� `/Q ACCOUNTWO OILY., ALO+ FAC1 i PE t:6OFi FEE INFO AMOUNT IIEWCTTFD lWqo6A2H NECOVED try DATE PEtIMTTISEIVICE RkOUMT lIlllr m INVOICE 3S. 2- �� pas X265 A i 0 15