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PPLICATION FOR WELLIPUMP PEHMr <br /> SAAQUIN COUNTY PUBLIC HEALTH SEES <br /> ENVIRONMENTAL.HEALTH D114SION <br /> 304 EAST WEBER AVENUE,STOCKTOM,CA 95202 <br /> (209)468-WO �f <br /> ION-REFURAAk PERMIT EXmas I'YfAR FROM DATE iSSU <br /> {Compi4tlt in TrtpRcllDyt (� <br /> APPLICATION 19 HERE SY MADE TO THE SAN JOAOUIN:COUNTY FOR A Pff"T TO CONSTRUCT AND!'OR INSTALL THE WORT DESCRIBED,THS APPLICATION$9 MADE-ItCOMPUANCE WITH SAN ; <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-111$.3 AND THE.STANDARDS OF SAN JOAOUIN COUNTY PU$LIC HEALTH SERVICES.ENVMKWNTAL HMT'N:OMSION, <br /> ,rte �.r��# /IfW � �L� �^^ fUZFtAPNf <br /> JOB AOMSMA APNO 6._z� J �JLI I CMY c' a �+ii1IGE4 <br /> DWNRR'b 14AME 3 fT3' /� ADDAEBB �Gr PP J PHONE a <br /> �� Ao <br /> wPr <br /> COMPACT" AII[XRESt3 ^+�4 � i UCf: D►tQw <br /> f _ <br />! StilB CONDRACTOR �i P'HOHE, I <br /> + P <br /> T'PE OF WELUPUMPt WNEWWELL 13 t1EPLACEmwr vmt Cl MONITORING WELL R 0 OTHER <br /> S ❑IHSIALLA ©:WELL SMIM REPAIR 0 CROS"ONNECT REPAIR Q vAPOR sx-mACTNJN WELL a :I <br /> •.! ❑.Natr© DEPTH PUMP SET PT i :MW WATER LP-'M 1 <br /> (TYPE OF PUMP) I-I <br /> C1:OVT:-OF-SEAVICE V4ZLt.. 4..I otop"YocAI',wem <br /> ❑.GeSTRUCTlQ N: I{ . <br /> ;3 <br /> INTENDED USE �rTYPE OF Well, .f CONsraUCHan aPEclFtcll''flQ�l {j{ <br /> A. <br /> 0 INDUSTRIAL: OPEN GOTTOM �I VIA.OF WELL EXCAVAt.10N, - WOAA.OOFFC400ETALLElASOINRG C+AMO <br /> OOOMESTICIMVATE [a/.""PACCTYPE:OFCASINOIBTEEI j <br /> d PUOMMUN1CtPAIL DHVEN OEPTH`OF GROUT SEAL <br /> D <br /> GROUT SEAL INSTAL t.ED ON <{kiOUT BRAt1D fiAltlE /' ltY1 trot.. � <br /> GROUT SEAL PIJMPEOt L.J Y. O pm i� CD��TE i'EOEBTAL.BTf w&uR,.n y. CIN" S <br /> .AiPROK.DERTtt .�' .:: LOCK sire :t oxmOVEIRK .. .S <br /> PRO►OSED CONSTAUCTIOMMMLUNO.MEr11 i�IA7WROTARY ABI.RCTARY AUGER �I CAiLE _ <br /> I+ { <br /> I.14MBY CERTIFY THAT I HAVE.PREPARED THIS AFFUCAT'ION AND THAT THE WORT WKL.SE OONE M ACCORDANCE WITH SAN JOAOUI I�L:;GHYK�ORDCNANNCEB,STATE.LAWS.AND D RULES AHO <br /> REGU ATIONB OF THE GAN JOAMM COUNTY.-#NONE OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWSNO.'I CERTIFY THAT MNTiRE PEHF01tlIMNCE OETIN YVOR+t FOR WHICH <br /> THIvP£RMITIStM",:I:SHALL NOT:EUlfFLOYP aSUBJECTTO.WORKMAN'SCOMF£N+IATIONLAWSOFCAUFORNIA.' CONTHACTOHBFBIOVBTHLSU8-CQNTRACTMGSIGNATURE-CERTIFIES <br /> . <br /> THE FOLLOWINOt ,_TCERTWY THAT IN THE PEFFORNIANCE--OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PER IONS SUBJECT TO WORIOMAN't COPAPOtOATION LAWS:OF <br /> CALIFORNIMTWAUT MUST CALL 2 II-ADVANCE FOR AtIPECTI,:GEMMED INSON!AT 112"M 441111111-24". COMPLETE ORAAXW AT LOWER AREA PROYMEO.X --fJ <br /> ftOT M A I Mfvw M 500141 Baale I*�iE� <br /> I<<.MAWS OF STREETS OR ROADS NEAREST TO OR 80tWOM THE PROPERTY. A. LOCATION OF HOUSE BEMtAGE DISPOSAL,BYBTEM OR PROPOSED <br /> 2.Y OUTLINE OF THE PROPERTY,OIVMlG DIMENSIONS AND NORTH DtMCTtON, "PANSION OF SEWAGE DtSPOSAI.SYSTERNS. <br /> 3.4 DIAEN>RONEO OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED {! S.LOCATION OF WELLS WITHIN RADIUS OF ONE HU NCWD FIFTY FT <br /> IiStRUCTURES..INCLUDING.GOItEREb AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR AOJOSNRIGG PROPERTY. <br /> + <br /> .... <br /> - <br /> nA-------------- <br /> ............ <br /> ....}, ......,.,......:... .... fff <br /> .........:. <br /> .............. <br /> OEPARTSUI�IT USE ONLY -! <br /> i <br /> AtiolleNton Aae"ted ft e®y'S.f �� ClyDe1+I Ane t <br /> Otu1A ke vft+te By LA.33i +1(�`r � . ... .. Oaty_ ' „�`'Paniy:I"000lld'I .ONS <br /> +f <br /> Da4lnatN4n:Irxaeetbn:By: Dote <br /> „ <br /> I� i <br /> 'x:ACCOUNTINOONIYt AIM FRCP { <br /> 'i <br /> II PC COIFS FEE INFO MSOUNT RIM ED CHM"ICASN REcCINVED BY DATE II P Nf178ERVICE REOUE/T NUN9gt <br /> Pdb:'HestMl Selo: eiviro.l]3.:(A/97): <br /> ,� <br />