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APAICATIDN �OR [lPUMP PERMIT 46 IT Fj SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 904 EAST WEBER AVEMM STOO(TOK CA (ZIIo) us=o. 2 rd door '0�16RIGINAL ILl1NOmmollou APPLICATION'S"M LTV MADE TO"MOM AAOUIN COUNTY FOR A re"Im TO CONSTTSX.T A DMIR INSTALL THE WORK DE APPLICATION APPLICATION w NIADE IN COMPLIACt WIM SAI JOAOUIN COUNTy DEVE,OpMo frrTML CHAPTER 0-1116.9 ARID THE STANDARDS OF SAN JOAOWN COtINTYpUiLIG HEALTH SEMMES E�NVIMONMENTAL HEALTH DIVISION. JOS AOOIIESiION AR7M1►1 OT [rrA Vit �,1 n Q _<Y t Cll ' i i r3�lu 7�� CITY_T roCITY -t- l PARCEL SIMAF.,._ t. 5 8 V o L,*Yv m o� v-3 Rte LIL n�^•S owleri NAME ! Lnrdozo. P f0��>^}7P'i.1vIL ADORED '.r'It 4'+Q t. 4Ft1 C q 9 PHHONE/+� b7b- le(e 77 COR�(TRACrOR1_. G•GOw.n M�ti C.oKS 1�Ay.�r + 1.- - AOOIEW-1 PST 'fhFj,S.F uctr 4 b 1-4su PHONE R SM CONTRACTOR rZgi ri l l i vt -- 9s0 /Y&-. ih e Z. A A�� ,d � LIC/ 485-IbS H�HIONEP4�S'313�900 HH vwt. Itak. TYPE of WELLIPUMDc ❑ HEw wEL ❑ REPLACEMENT WELL ❑ MONRVWNM WELL I ❑ oTlltw ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CRO=16C�IItPAw ❑ VAPOR Mnn^CTHON WELL P J ❑N.w❑R.S+ H.P. DEPTN PUMA SET�PT. FIRST WATER LEVEL G rrrrE of PUMIII - ❑ our-orsEanneE WEL ❑ GEon/roCAL Vau P ❑ SOIL Down , s DEnI11IeTION: Cx-9, EX-10_. E X-r 1 , I!1 w-3 Int w-4 INTERD®WE of W CONI i TIONS A ❑ INDUSTRIAL ❑oPEN SaTroM DIA.OF WELL EXCAVATMN OUR.OF CONDUCTOR CASING p ❑ DGMESTICIPNvATE ❑GRAvm PAougm TYPE OF CAtINGffnmL►vc DIA.OF WELL CASIIG p ❑ FUSIIGMUMICAAL ❑owvm DEPTH OF OID1R SEAL SpEaFIewTHON A ❑OSSGATIONRAG ❑OT"m amx f SEAL W WAI a BY GROUT LSHAND NAME E 13MONRORINi a11DUT TEAL Ptawm-C]v. ❑w eoNcwTE PEDESTAL SY owLLE1l:❑Y. ❑N. s APPROL DsrH LOCKING CHESTER SOXWFOVE PlP s PROPO LLMG METHOD' MUD ROTARY AIR MWARY AUGER CASTE OTHER 1 HEESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE M ACC)ROANCE WIN SAN JOAQUIN COUNTY OIOSHANCEII.STATE LAWS.AND RULES AN[ REGULATIONS OF THE SAN JOAQUIN COIWTY. HOSE OWNER OR LICENSED AGENTS=NATURE CER THE POLIDPNNS'1 CE.IVIPY THAT IN THE PEMFOIMSANCE OF THE WORK FOR WHICH HIISH TS PERIS ISSUED,I SHALL NOT EMPLOY PERSONS VjLXCT TO WOINWAAN•S C"MMINSATHON LAWS OF CAUFOWSI1,• CONTRACTORS HWWIG ORDS-CONTRAQTND MONATUM COMFIEI THE FOLLOWING' ' CERTIFY THAT IN THE PERFORMANCE OF THE WORK POR SPRACH THIS PE INV It NMKNW.I SHALL BEPLOY PENN)"SIIVECT TO WOFAM& S CompopATHON LAWS OI CAUWIWpI\' ANT tlHif CALL 74 HOURS M ADVANCS MR ALL RE01101110,INSPECTION/AT OSS)490MML CONFLATE DRAWING AT LOWER MEA PROVIDED- =Pod X TRY. Sr 1jl jAd j"M l Q 15f pR� _/ 5y.kA4w 1190 PLOT MAI SNSw M S.I./SyM r t. NAMES OF RiEITS 011 RIEIIIElf TO OR SOtMOIPq THE PROPf)RY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. oUrL11E OF THE PROPERTY,o1VIH0 DS`EHSIDNs AND NORTH DIECIION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. a. DIMENSIONED OURINFA AND LOCATION OF ALL EXISTING AND PROPOSED G. LOCATION OF WELLS WITHIN RAORIS OF ONE HUNDRED FIFTY FT. STM1CTUR11 .I CUR WX COVERED AREAS SUCH AS PATIOS,OWWRWAYS.AND WALKS. CN THE PR 14MY OR ADJOINING PIDPEITrV- : :::z MAP 4N BACK ...... ............... ............ ...... .......... ........ ....... ................................. ...... ............ .... ....... ............ . ........... ...... .... ....., . . .............. ....... --- .................... ..... .............. ................... DtlATTIIE6ET WE ONLY ArWlrtls�A...PI.rI M oa. A,06 Grout IN upw0m Sy Dn. I'L"m bmp—" —ST DSU D.1rusli.n b+P.wLn D.t. . Csnnl.nHr. 12 f e ACCOLI.—ONLY: Aryl FAG PE CODSS ra LIFO AMOLINr ROYiTTED MPL ASN IBEIVLIp Sy DATE po"flSSIMCE ommusST NNNtEEI INVOICE S'g9 1.1n)4 A InL.JC= :17 OCC