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11-05-1997 1:SSPM FROM P.2 <br />APPLICATION FOR WELIJPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />IllGII-REfOMOABIE PERMIT EXPIRES I TEAR FROM DATE ISSUED <br />C\V- MkIwisu Is Triplkrtel <br />APPLICATION 16 HERE BY U TO THE PAN JOAOLM C'OLAVTY FDR A PEFUMT TO CONSTRUCT ANOATR INSTALL TIIE WOR( DESCMUW. T"m APPLICATION B LADE M CO"PLIANCE VM II SAN <br />JOAOUIN COUNTY DEVEIL0V%&0(r TTM -F- C"ArrEk 9-111 S-3 AND THE STANOAROB OF PAN JOA(XM COUNTY PUPM HEALTH PERVICM EMIRDMUI£MA£ WALTN OMMGN- <br />AB AOOREESAR APNI 1��, TV' j' IC (S -r /CITY (, PARCEl P�JAgNI <br />vo <br />OWNEn-S NAME ADORL$e <br />Plto'IN£ r <br />CONTRACTOR � L; �' t c <br />P/v, �. y✓1LvCy7� i� 1 AOOnL6e fY^:lv�('!f_i K�I�t� t1C rFNONEt <br />6U5 coNTRncron'�ni G_f.E UIQ' `J(. �I�n(- ��i.rJ AaOR[ti i�/4 /',T2c.O., �d KC/ tt e�+oNE r�7 �U"63G'/[-7E <br />J � <br />TYPE Of)! Eq lJ ump-' ❑ NEw Wat. ❑ REPLACEMENT WILL Q "OmTom-a wEli r ❑ OTTtln <br />❑ DNSTAt ATPON ❑ WELL UYSTEM REPAIR ❑ CHOSS•COFogCT PETALS ❑ VAPOR EXTRACTION WT -U t i <br />Q N.. ❑ /L.pir N V - <br />(TYPE OF PUILAM <br />❑ oUT4F6ET+VICE -'Eu <br />❑ GES-mvcTION; <br />or"" PVW SET R. F(RPT WATER LLVLL. <br />❑ GEOT`fIY61CAt. W"J. r ❑ BotL DOSING <br />INTENDED Ut[ TYM OF WELL CON&TAU2Tfolf Spf4UPiCAT10Nt A <br />.....:....:.....: . <br />❑ Y+OVSTMAL ❑ OPEN eoTTO►t VIA. Of WELL EXCAVATION DW OF CONDUCTOR CASINO <br />^ <br />❑ DOMESTIC/PRIVATE ❑ GRAVEL PACXtg2E TYPE OF CA..nMTalj9%'C �VCi VIA, OF WELL CASINO <br />..... ....,.. ,......:...........:.... <br />Cl PVBL/C/FNNICTPAL ❑ om%'TN OEM14 Of GROUT SEAL I • '�, -411 - SPTCIFICATION t <br />a <br />❑ IRIIIGATIOWAG Cl OTWtA GROUT SEAL WTTALLED BY GROUT BRAND NAlAf L <br />M ❑ ❑ ❑ ❑ <br />FdONO'oTIIFFO GPOUT SEAL PVT.TPEo' Y.. IE. CONCRETE MMUTAL BY DMUX't Yw Fw $ <br />AP"0X. DOTH LOCKING' CHESTER BOXISTOVE PIPE s <br />m CXG MV400. 1AUD ROTARY AIR TARY ? 1 ..�,�1UGCR OTHER <br />—OPOeONITROCTTIDKMMLURO <br />\ n <br />DEPART"Goir LIGE ONLY <br />1 HEVEeY CERTIFY THAT I NAVE PREPARED THIS APPIJCATTON ANO THAT THE WORC WILD. BE DONE M ACCOROANCt WITH SAN JOADVIN COUNTY ORDINANCES- STATE LAWS. AND RULES AND <br />M CULATIONA OF THE SAN JOAOUM COUNTY_ 140ME OVJNLR OR UCET16£D AGENT'6 6tGNAT09E CERTIFIED 114E FIDUOWfN0: -1 CETLTIFV THAT IN TNT PERTOWAANC£ OF TML WORK FOR KMTCH <br />Awso.,§— A -04.d eT <br />LL.e.R r..Pmcb.. el <br />THIS PEP"IT t8 ISSUED. 1 SHALL NOT E7JPLOY KRDONS 6V8-tFCT TO WORKMAN'S CW.LP4feATION LAWS OF CALIFORNLA.' CONTRACTOR'S HRIlNO OR 4UB-CONTRACTMO MNATVRE CO(TIFTES <br />ORt• <br />THE FOLLOWING: - I CERTIFY THAT M+ TI/E PEWomiANCE OF TLFE WOM FOR WHICH THIS rIFF04IT 18 IBSUMD I SHALL E}IPLOY PLI160Ne 6URACT TO WOIIIiMAIT-e COAAr"&ATION L.AWII OF <br />(F� <br />CAA-WOMIA.- THE APPLICANT MUet GAIL M HOTIRs fR ADVANttT FOR ACL RTOIIRm TIi16}41;TIVIse AT 0oe1 Ao it p, COULILTE OMIIvtNO AT LOWER AREA PROv1D>Ep, <br />L -0c) <br />610-- i— /�... TM. �, �( /.�.D.I._ I .D - 0c) <br />(\J� <br />ROOT FLAX (D.M 1. Sa.W 2.woI tI - <br />W <br />1. NAUE6 OF tTTIIEETS OR ROADS NEAREST TO OR BOVNDIVO THE MOPETTY. f, LOCATION OF HOUSE NWAGE 0191"OBAL 9TVTUA OR PROPOSED <br />2. OUTLINE OP THE PROPERTY. GCV*M OVAEWOONS AND MKTM OtMCTtON. EXPANBgN Of eEWAOE OIPP'OPAL eTSTEus_ <br />-f^ <br />7. 04AENWONEO OLIFIIWS ANO LOCATION Of ALL EXISTMU ANO PROPOSED 6_ LOCATION OF WET LS WT M PUIM8 Or ONE WJNDPCO PWTY FT. <br />r,TRUCTVNIE3, INCLUOING COVOWD AFD'A8 GtICH As PATIOR. VMVEWAYS, AND WAtXS. ON THE PNOPERTY OR ADJODRNO PP"ERrY, <br />•. -. <br />5 A�...r. A CAi f- <br />.....:....:.....: . <br />IR COOED <br />FEE I WO <br />..... ....,.. ,......:...........:.... <br />CHCLKsIc"" <br />(60-3Z <br />a <br />WeVOt" <br />\ n <br />DEPART"Goir LIGE ONLY <br />/ <br />Awso.,§— A -04.d eT <br />LL.e.R r..Pmcb.. el <br />PLvnp tl,.pIIIId „ e. <br />ORt• <br />O.L. <br />C Is—t.: <br />ACCOLI(TING ONLYt <br />AIII/ FACS <br />IR COOED <br />FEE I WO <br />AFAOIFNT RjmatTED <br />CHCLKsIc"" <br />(60-3Z <br />RTCt3lem 6Y VATE ISTRMCE T <br />� (, S1QeD2 7-7�Z <br />WeVOt" <br />pub. Hestth Serv. - Envko. 173 (1197) <br />