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APPLICATION FUR WFLLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES_ (� ENVIRONMENTAL HEALTH DIVISION IV/ P.O, BOX 3M 304 EAST WEBER AVENUE, STOCKTON, CA 9 � �iV,,,n .l (�, ,�REFU 12091 468-3420 40P `/u- (O f� ' MLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Al •�`�J (C"Inplats In Trl�fkllt�) A .AiION IS IIFRE RY MA TO 7HF RAN JOAOI)IN Co1RNV Ton A PERMIT 70 CONRi R11CT ANnlon INRTAII.TIIE Worn(DFpCninFo.TIUR Arm ICAT ION IS MADE IN C.ORAMIANCE MI II RAID JOAOUIN COUNTY DEVELOPMFNT TITLE,CHAPTER 9-1115.3 AND TIII�I RtAN()Anr)A Or RAN JOAOUIN COUNTY PIRLIC HFALT II RFnVICFR,EIJVInON1./FEJT ALIIF AL T II DIVIRInN. JON ADDRESS/On APNI_,?O -Sgn ,.l � S( +CU c {I�/ C� clr-r ��.; . PARCELRlrrrAPJ• ZD 2 S'p �OWIJFn'p NArE / /Y/l/ TU._S J� J n Cy-y�.____ j- ADDRESS 20 Ip Z _54ti `� 1C�1f'J fy IONF I oJc• -�2R�_— r`h' TLlpTI��! SE/V 1 CtS ---ADOREas F("7Ofns'r y(�n SIltv�trL��_ y�__�IS 3C I�InaF S/3Z-bo2L RVR CONT nACiOn V • �M11 U�1 Ill.�ln_ r-D(74�(S� n10NE ---� ADnRERP. — TYPE OF WELL/PL)MP; CK NFW WELL ❑ nEPLACFIAFPIT WELL 14MONI70nING WFLI.JI ❑ Oi11FR ❑ INSTAII_ATION Ll WEU.syrTEM nFPAIn LlCnOaR.CONNECT nFP/Un ❑ VAPOR EXTRACTION WEIL• ❑Jlww J ❑Rwcrdr ILP. DFPTH PIMP SET P R VPF OF PL/MPI T. fIRRT WATER LEVEL 11O ❑ OUT-OF-REnVICE WEU- ElOFOMIYRICM.WEI L I_ ❑ ROIL BORING n bE11i nl1CTION: —`— E----E TYPE OF WELL CON6IRVCIION SPECIFICg110N6 - ❑ INDUST SIALn ❑OPEN BOTTOM DIA.OF Writ.EXCAVATION L_; - - ►Y/ ❑ DIA.OF CONDI/ ❑ DoMESTIC/PRIVATF. ® rV nnAVEL PACK 11111E N� S'Tna TYPE Or CAnINnlrTEF1/PV AefN CARINq_/I ,A !r _. OIA.OF WFIL CASINO PVRUC/MVNlCIPAL ❑DRIVEN DEPTH OF oROIIT RFAI. •— ❑ innln ATIONIAG ❑OTHER _ SPECIFICATION R GROUT RFAI.INRT AIIFD pY ® MONITORING GnOUT BRAND NAME. J\ ,F APMGX.DE1{ � GROUT REAL P/MPED: ❑Y— ❑Ne CONCnFTEPEDFRUI.RYDnnlFn:❑Y« [IN. S LOCKING CIIF.RTEn ROX/R1OVF.r`IPr r'ROI`ORFD CONSTRl1C TION/DitlLUNO METHOD: MIID ROiA � _ J qs Ain noI AnY AUGFFI CARLF OiHFR —_ I IIERFRY CFn1IFY MAT 111AVE PREPARED THIS AMICATt N AND THAT THE RK W11.1-RF NE IN ACCORDANCE WIT11 RAN JOAO111N COUNTY OMiN ANCE RI '/`/�/i/(• nFnut ATIONR OF TIIF RAN JOAOUIN COUNTY. IIOMF OWNFIT On LICFNRFD AnFNT'a MONAI UTIF.CFRT IriER TNF r011 OWING:-1 CFRT IFI THAT IN TIIE PF A ORM ANNE OF TIIE .AN FULES ANO ANTI 11118 PERMIT IN IRRUFD,1 RIIAI L NOT EMPLOY PFnRONR RURJECT TO WORKMAN'S COMtENRATIGN LAWS Or CAIIrOnNIA.• CONTRACTOn'a IIInINo OR RUR C_ONTRAOTING RIn NAtt)nF CrRTP1ER THF FOLLOWING: I CFRfIFY TIIA1 IN TIIE('ERFORMANCE Or 711E WOrK fOR Vr111C11 TIIIA PERMS Ip Ip RUED,11111A1L EMPLOY IEnRONR 111/RJECT 10 WORrM ANY COMI•FNSA TION 1 AWP OF CALIFORNIA.' T{ APPLICAANNI MVS CA 24 HOUnS IN AnVANCE FOR AIL REQUIRED INSPFCTIONS AT 12091100.1411, COMPLETE DRAWING AT IOWEn AnFA P"OVIDFO. Slar-A X > Tmw , ! ''—=-j---�1 Dow Plot PLAN In—In 9—J.)Rnwlw le I. NAMFR or STnFFr11 OR ROADS NEAREST TO on ROUNDING TIIE PROIFntY. 2. OUTLINE-OF ME PROPFr"Y,GIVING DIMENSIONS AND NORTH DInFCT10N. 4- tOCAIION or IIo1JpF SFWAOE OIRPORAL SYSTEM on PROPo RFb 3. DIMENSIONED OUTIJNFA AND LOCATION OF AtL EXISTING AND PROPOSED F.XPANRION or PFWApE DIAPONAL 11YRIF/Aa. STRUVRE R,INCLVbINO COVERED AREAS RVCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION Or WFI L11 WRIIIN FtAn111R or ONE Htl?JDnFD EIrTY n. ON TIIE PtOPERTY On ADJOINING PROPERTY. N 3 � � p a $ 1 1 j c, PURI iC H aro M ENVIRON 1EN Eli bFPMTMFNT VSE ONLY ` y Appllcwnnn A..mtel Ry Grmn In.p,vtlwO fly D•tw /� ' _�wne I—r—flnn NY D•Iw bn.tr,rollnn I—P—lnn NY --- - 7` Cnmmnr,l.: `�I �/ •, I,�Ya _ .✓ ��_�7��y�i��..L_111�-__��_.�7--�---��L_ '- `s�. ACCOUNTING ONLY; AID/ 1 FACS G f PE COnFa FEE INTO AMOUNT REMITIED CIIECKryCASII_I RECEIVED NY DATE PvWIT/SFJRVICE REOVF.RT Nwmpn INVOICE Pub.Health Serv.-Enviro. 173(3/96)