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APPLICATION FOR WELLIPUMP PERMIT F(7,f7;V <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION SEP 2 2 1998 <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202..NVIFI(1fVUL:n7Al. <br /> (209)468-3420 <br /> NON•REFUNDAKE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I�Ef'n�lli /` I=1 I�fi(.•I <br /> ICImplete IN TTIPReEII) <br /> AMICAI ION IN HERE MY MADE TO TIE BAN JOAOVIN COUNTY roll A IERMT TO CONSTRUCT ANDIOM INSTALL THE WORK DESCRIBED.TION AAlICAT10N IN MADE N COMMIANCE Ml II SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER <br /> 9.11 1S.3 AND THESTANDARDSOF BAN JOAOUM CODUNTTY�AmUC HEALTH SERVICE@,ENVIRONMENTAL HEALTH OMRIONN../ <br /> JON AODRE@SXfR AA!# /O/ ;/'Lf'/fVl— •�/ Cory Coo/ PAFY.EL SITEIAAI# / /?T_ <br /> OW Wn'I NAME_7,,2/C M11 &El:U? 7 AIIDnEe@,FV1C d2 1.�00Dy13��•GID� g P7x,11OZZ Ag <br /> AaNE I/ <br /> CONTRACTOR (1J� ADORES@ • /CESesdlG.f�# NE I ,/,/QED <br /> LO <br /> eve CONTRACTOR AOTTRESS LFCI AroM <br /> TYPE OF WEWMIMR ❑�y� NFV!WELL 11PEMCEMEM WELL ❑MONNONNO WELL F ❑OTHER <br /> EJ INSTALLATION Cl WELL SYeTEM nEPAM ❑CnOSSCONMCT REPAIR ❑VAPOR EXTRACTION WELL I J <br /> ❑Nrw O Ion 1, II.P. RECTA PUMP art FT. rMmT WATER LEM O <br /> RY/E OF IRTMrf <br /> ❑OUT Or SEnV10E WEII ❑OEOA1V51CAI WELL 1 R BOmNG B <br /> ❑Df ei1111CigN: <br /> Nf ENDED t Y BO <br /> CONtIVIUCTION SPECIFICATIONS /7•- A <br /> lJ INf11/ST RAI ❑OPEN BO fTOM MA.OF WELL EXCAVATION �] IMA,Or CONDI/CTOn CABIN 1014 N <br /> ❑DOWILl ICNATYPE OF❑ORAVEI PACKMDf TYOF CA.TEIQMtyfUFVC 0VM DIA.OF WELL CASINO O <br /> 1❑I-.MANUCIMUMCII'AL ❑DRIVEN MIPT I Of GROUT SEAL 4T" SISCIFICATION S <br /> LJ AIIONTAO ❑OTHER GROUT SEAL WWAU,EO MY `Ni GROUT @MND NAME E <br /> U MDMTORNO / OROUT OVAL PUMEED:O Y- p 1. �jP� CONCRETE PEDESTAL @Y DRRLER:0 Yw N. S <br /> AMI10X.DE►TH 4� LOCKIA CHESTER NOTUSIOVE AIS N/K J� �/ S <br /> PROMBED COMSTRUCTIONTDRILJMS METHOD:MUD"OVARY AM NOTARY AUGER '-'TCAARl-F OTHFRyly( <br /> l IIE'ENY CERTIFY THAI I HAVE FTEPARED TINS AFPUCATION AMT THAT 111E WO1K WKL ME GONE W ACCORDANCE YATH SAN JOAOUW COUNTY DII GIANCEO,STATE LAWS,AND MR-KO ANO <br /> MUTN GULATION9 OF THE BAN JOAOCOUNTY.AURAE ONWEM ON LICEN/ED AOFNT'@ IIONATURE CfFIIIFR@ THE rOLLWI <br /> ONO:•1 CEIIIIFY THAT W PERFORMANCE THE PEORMANCE OTHE WOM TOR LMSCH <br /> TMS F'EIIMIT IN ISOUEO,1 SI/ALL NOT EMPLOY IRfMOONS IKNIJICT TO WORKMAN'S COMM 16ATION LAW@ Of CALIFORNIA.'CONTRACTOR'S MRNO OR M/OCOMMCTIHG NIONAtU/lE CLMT1rE0 <br /> THE FOLLOWING: •1 CERTIFY TPEIEOR.IA E Of TER WORK ran W111CN TMNTRM <br /> S PERMIT IS ISSUED.I AIL EMPLOY PEneONO 9UOJECT TO WORIOAAM'S COMPOIBATMM tAWO OF <br /> CAUfOAA'IICAI MVST C 10 SOUR 1 ADVANCE FON Aid.-"— 11EO11111 MCt10NO AI I/M/S•-rI�SM-2/10.COM�RyEt�E DINNIIM AT LOWER AREA PROVIDED. <br /> PLOT PIAN Idrw I.Se.l.l M.1. 'le <br /> 1.NAMEN Of NTREEft OR TOADS WARIEST TO On BOUNDING THE FROI'EI IV. 4.LOCATION Or HOUSE SEWAGE DISPOSAL SYSTEM On 1TOMPTO <br /> J.OMINR Of TIE FYIOPERTY,GIVING MWN@IONS AND NORTH DIRECTION. EXPANMN OF OEWAOE DISPOSAL OVOTEMO. <br /> f.DI#ENOTOMD OUTlTNFO AND LOCATION OF ALL EXISTRRI AND"10FOSEO S.LOCATION OF WFLLS WITHIN MOIUS OF ONE EII/NOIEO FIFTY R. <br /> ITRUCTURIM,INCLUDING COVERED AFEAS SUCH M fATIOO,DRVEWAYS,AND WAIXe. ON THE PROPERTY OR ADJOIMNO RIOPEATY, <br /> 1 � : <br /> i <br /> i <br /> 1 <br /> DtFMTMENT UOE ONLY —/f <br /> n—.I,.Nm..1e,.PT M.;44 .1.lQ / 0 A...E xrPlnlla.@Y DN. <br /> On.InclNn IrwPrlbn BY D.I. <br /> CnmmwNr• <br /> ACCO UNiNO 01l1Y: A1DI FAC# <br /> FE CODES FEE INTO AMOUNT MEMITTED C/ECKFICAWI RECOVED EY DATE 1`9I0TTIFAVICE REOUEIt NLPARIA INVOICE <br /> a1 a DO <br /> Pub 4804h Sent.-ERRBo.173(1/97) <br />