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r. APPLICATION FOR WELL1PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EHVIRONMEWT'AL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST YYEBER AYENUF,STMMN% CA 9=1,W <br /> (2091 488420 <br /> ROH-REFUHOARLE PERMiT_[XA}RES I YEAR FROM DATE ISSUED <br /> A (compute is Tr(ptieatLi <br /> APPLICATION 18 HERE IIY MAGE TO THE*AR JOACUDR COUNTY FOR A PEAMIT TO COIRSTRi<ICT AMMR INSTAL.THE VMjK DESCRIBED.TMS AM=TION III MACE W COMP <br /> JOAOUIN COUNTY DEVELOW.IENT TITLE,CHAPTER S.I 115.3 AND <br /> THE STANOAROS OF BAN.JOAOUOR COUNTY pUUM HEALTH SERVICES.Dr4IROHMENTAL HEALTH DIIJANCE WITH 5;,. <br /> 108 AODRE881pR APNVIM".I n r T J.P CITY -L• QV1 <br /> - PARCEL SQElAR'Nf 3- % .•� <br /> OWNER'S NAME '57ADDRESS 1 t S PHONE F f, _ 2 <br /> COMW=OR �(�� j HT1.Kt'J., or i 10Lycc <br /> ADDRESS O' t dL LICK_PHONE/_g —-601 <br /> BUB CO!N1'RACSOR <br /> ADallEii LICE- PHONE l <br /> ,f <br /> TYPE OF WELIJF MP. ❑ NEW WELL ❑ RIEPLACEMENT WE L 0 mawiORIIW WELL., ❑ aTHE11 <br /> ❑ INSTALLATION ❑ wELL avwrW REAADt ❑ CROSSCONNECT FXPAIK ❑ VAPoR cnwz ON WELL. <br /> ` ❑New❑P,,& Hp. - i <br /> (TYPE OF PVMPI DET'TH PI!!aP - r+FIRST WATM LEVEL <br /> ❑ ouT4"ERvICE WELL ❑ GEOPHYWCAL WELL I la E 80iL BOFeNO- � - <br /> Cl DESTRUCTION! 6 <br /> INTENDED V;E TYPE GLW" OH; tA:T K; A SNL I <br /> ❑ INDUSTRIAL ❑OPEN BaTToM DNA.OF WELL EXCAVATION_ _ A I <br /> ❑ DOMESTIC/pWvATE ❑CRAWL PAOUsmk .. lasA_OF CONdOUCT�Ofl cAawa /Y/ C <br /> y TVP!OF CASARQATEELIPyC OMS OF WEELL CASINO c <br /> ❑ PUSLIClLdUNRC1PAL ❑GRIVEN WrH OF QROUT SEAL - aCG SPECIFICATION <br /> I <br /> ❑ W OATIONIAO E3ILEA <br /> OTHER GROUT L WSTALIM BY C DIS R <br /> MONITORING _ GROUT*EALPULRPEa:®Y. - QAOUT BRAND NAME <br /> 1 ❑U. CONCRETE PEDESTAL BY DRILLER:❑Yw ❑Na s <br /> APRta](.:aE►'Tli_ r J ' Wr.=M CHESTER SOXNTOW RIPE N//f - �• <br /> s <br /> PROPOSED coNBTRUCTiaNraRaluNo Mk7HOD1 Lrup ROTARY AIR rw: AUGM -IDTHEyt <br /> I I <br /> I, <br /> I HEREBY CERTIFY THAT I HAVE PREPAAw THIS APPLICATION AND THAT THE MOK WILL Be DONE IN ACCORIDANCE WITH SAN JOAQUIN COUNTY O 1 - ! <br /> RaRNANCEq,RTwTE LAWS.Ilr+o RULER wN; <br /> REOULATlONB OF THE BAR JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SRGNATURE CER. <br /> MEB THE FOLLOW WQs'I CERTIFYTHAT W THE PERFORMANCE OF THE WORK FOR WHIC, f <br /> THIS POW IS ISSUED.1*HALL NOT EMPLOY PERSONS SUBJECTTO WOIgGIA/WS COMPOISATION LAWS OF CALWOM"' CONTRACTOR'S MIVNO OR SU34ONTRACTIND SIGNATURE CERTIFIE: <br /> THE FOIIOWING: 'I CERTIFY THAT W RMANCE OF THE WORK FOR WHICH THIS PEIWr IB ISiUEa.1 SHALL DA WY PERSONS SUS=T TO WORIQYIASN'a CCU 71010 LAWS a: <br /> CALIFORNBA.' AP*!1 ST C HOURS ADVANCE MR ALL REOLSROf IRBPSCTWN6 AT MWI40 37. COLWLM OMWIN4 AT LO A" <br /> AREA PROViaEp. y <br /> elo,,.a z nw Af _ a.,.zl/ <br /> I PLOT PLAN Crew to Saa W Sada -tr iJ <br /> 1. NAMES OF STREETS OR 6 NEAREST TO OR BOUNOOq THE PRQRfJTTY. .1 4. LOCATION OF HOUSE SEWAGE OtWOSAL SYSTEM OR PROPOSED I <br /> L OUTLINE OF THE PR0 O.CrVV DIMEHWONS AND NORTH DIRECTION. EXPANSION OF SEWAQE O[BPOSAL SYSTEMS <br /> 7. oD.IEN*IDNEc O AM LOCATION OF ALL E7tLSTprO AND R4fOPOSED C LOCATION OF WELLS WITHIN RATrUS Op ONE HUNOR C FwTY FT. <br /> I TRUCTUIREB.INCLUOUM COVERED AREAS SUCH AS PATIOS DR IVEWAM AND WALKL ON THE PROPERTY OR AOUCININQ VMPOCTY. i <br /> e......:.. -.i -...:......e......� ..:......:..... - <br /> ! DEPARTMeNy USS ONLY i <br /> AppLaat an A mptad BY Data 7 /J <br /> Grow 6hpaatlm By Dab Pttuut♦Mrpa+tlon RT b - - <br /> If Oa <br /> Ortnwdun Irwpeadan ByX! 11449METY10 <br /> Y I <br /> ACCOUNTNO ONLY: AIDS FACS <br /> PS CODES FOE INFO AMo%wT RiTIIUTTEa C1;OMICASH RECOV@ sY DATE POWTISUMCE REQUEST NI!l m INVOICE <br /> -� 1 <br />