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„ -2/ <br />APPLICATION FOR WEWPUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 4$8-3420 <br />lag -REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUER <br />MomploW M TI+DIBe61 <br />APPLICATION IR HERE BY MADE TO THE RAN JOAOM COUNTY FOR A PERMIT TO CONSTRUCT ANOJOR W STALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WRI1 SAN <br />JOADUA! COUNTY OEVELOF]JENT /RLE, CHA ER 5-1116.3 MIO THEBTAHOAJIOS OF SAN JOAOINN COUNTY PURLx: HEALTH SERVICER, PAIRONIAWNTAL HEALTH OMSION. <br />JOB ADDPSBBIO ob CG rARCEL SU:FJ/JNA <br />OWUIER'S NAME OY L <br />AOOIEBS <br />�J RgNE f ' <br />- <br />RgNE f <br />RL! CONTMC70R�y AOOIEee LICI <br />PHONE <br />TYPE OF WELLJPUMPI ❑ NEW WLLL ❑ HEPIACEAEENT WELL ❑ MONTTORI1a wm f II OTHER <br />❑ INSTALLATION ❑ VAEL TEM REPAIR 11CROSSCONNECT REPAIR ❑ VAPOR fXTRAIO <br />CTN WEU. F <br />❑N -9(p -W H.►,DEPTH RUMP SFT FT. FIRST WATER LEVET. <br />(TYPE OF RILPPI v ` <br />OIFTOF"BERNCE WELL OEORI/fWAL) /1WELL A ❑ Spn, samm <br />Q RU <br />ofSTCiMR.- <br />1 , 411 UJ j • y�'i'y/I' � �,� <br />LT—t— E. L. USE iY►! CONSTRUC ION SPECIFICATIONS T17✓ A_~� <br />13 RMSTRAL 11 OPEN BOTTOM DIA" OF WELL EXCAVATION OIA.OFCOf10UCIORCAMNO p� <br />U DOMESTIC&F VATE Q GRAVEL PACIUSITE TYPE OF CASM(STEILAIVC dA. Of WELL CARRA <br />❑ JC <br />PIRdMLUPRCUPAL OOMAEH bEPTN OF GROUT SEAL WNCIFICATWN <br />❑ IIBiIaATUON/AO UT ❑ OTHER OROVT SEAL INBTALIED 111 ❑ f- OROVT WAND NAME �-T E �� <br />Q MUMTORNa - OAOSEALK” MEOC Q Y- N. CONCRETE PEDESTAL BY ORRLEIE ❑ Y+ Qw s <br />APTOK, .S m LOCKINO CHEBTFR Bnx#Tow RPE f P <br />PROPOSED CONSTRUer"'b"'LL1Nd hMI400: MIA AOTARY___ AM ROTARY AUGER_ CABLE OTHER <br />1 "BY CERTIFY THAT I IIAVE PIFPARED TNS ATI'l1CATION AHo TNAT 1'HE WRAC LNTIA BE DONE M AACCORIAWGE WITH SAJ( JOAOIMN COUNtY o1OINANCES, SfA1E tAWS, AND RIREB AN <br />b <br />PIRIMATIONI OF THE BAN JOA" COUNTF. HOME OWNER OR LMWKO A F.M'S SIONATURE CERTIFIES TNF FOLLONMO! T CERTIFY THAT IN THR PEPfOPRIANCE OF TINE WORK FOR NRRCH <br />TIBB PEMJJT b N"UEO, 1 slALL NOT [MIiOY RRSOf# SUBJECT TO WORKMAN'S COMPI NSATION LAN" Of CALIFORNIA.- CONTRACTOR'S IBR//O OR SUBCORTM,CTR/O S/aNANRE CERTIFIES <br />THE FOLL71;;A <br />1 CERTIFY TNAT M T!E "MIl KIANCE m THE WD FOR WlSCH THIS PERMIT # ISSU@, t SHALL EMPLOY PRISONS SUBJECT TO WORIOEAN't COMPONATION LAN# Of <br />C N AT "ALL 110 SN ADVANCE fNE4TJ111FD 110TH A 70914409 >Nb. COMPLETE DRAINING AT LOWER AREA TONGED. <br />Blas+ x41", mm. <br />ROT PLAN ID.t.Y la Pe S..'. ' ro <br />1. NAMES OF STREETS OR ITOADS NEAREST 70 OR SOLNIDM THE PROr MV. S. LDCATXW OF NOUSE BtWAat PSPoSAL SYSTEM OR I,"MSEO <br />]. OVTLWE OF THE PROPERTY. nrvm DwLENRONS AM NORTH DI ECIION. EXPANSION OF MYAO! DISPOSAL SYSTEMS. <br />]. OMlHOONFD oUTt"@ AIM LOCATION OP ALL EXISTING AND PFIWQSEG S LOC.f.. rN w..I ..u— ...,......-- -- <br />i <br />u <br />1 <br />i <br />P.AY" t -W <br />OCT -2 3 1998 <br />ei•:1r;Ht�IphIENTAt. I":;A'-FN TPJ,• <br />DIP."TPAVIT USt ONLY <br />neFxe.11M A.e.el.d et,• � D•„ 3 <br />O.n.R 1,.1Penelen EL_ O.1• Rvn. b.F.otlenJBY <br />D,wt..clbn MPctb� �1 l e O.e. <br />Cemmbw.:� �1!/1 A .-t � :i �(>�����.r-»-^ (�/ /•-�—/� ; T i� 424 <br />c L 0d <br />U.I. <br />ACCOVNTINO ONLY: A101 FACE <br />IF COLE. FIE INTO <br />D s o-- <br />AMVtMT RERIFrIM <br />o <br />HECX ASN <br />RECOVED BY DATE POV.BTJSERVICE RE FT NLFAIOL <br />IJNOICI <br />ylrfl <br />Pub `49afth Sari - Envwo 173 ILI'97) <br />