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ai <br /> APPLICATION FOR WELL/PUMP PERMIT.. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE' 'ES <br /> 4r✓ ENVIRONMENTAL HEALTH DIVISION/ <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> 18011"REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS 1IERE BY MAGE TO TNF SµJOAOUIN (complete M Tf1pBaet{I <br /> COUMV FON A PEII IT TO CONSTRUCT AND)DR NSTALL THE WORK DESCmsEO.TIM APPLICATION IS MAGE N COMPt1A10E WITH Sµ <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND TINT STANDARDS Of SµJOAOUN COUNTY PUBLIC IWALTIL SERVICES.ENVIIIONMEMAL HEALTH RIVING((. <br /> Joe AOOIIESSMDR ARM Zo•J S f����J,,�11tdA S 4. CIT,AOA-C CN <br /> OWNEWS NAME APS AA ty rl R$ PARCEL{KEU/NS ��CC.. {{�� (-T Q <br /> ADDIIESS ZSJ3 S 1-Ltilt�lV1 SE- PNONff(I_` `+Z3 —S}28 <br /> CONTRACTOR Sy%�I•v% 1 Lt1ARA.3�aT5�1 CE)YDd VYL�t.i Len AOOIIEes'�iaQ �/"N�R.c..i O T i V'L11csS W UO l P,*.f 571-7.L L 1 <br /> sive COMRACTOR 1'i5t�t L�nU:�Wltve.tA{a I N t� 4£('3X65 .Zatf,;5 <br /> ADOIIEM� RIONE <br /> /��.yl�Cr <br /> TYPE Of WtLL/PUA1Pt ❑ww WELL ❑RFNACEMEM WELL ❑MoNITRN <br /> OO WELL• 13 Grimm v• -n <br /> ❑PASTA IATioN ❑WELL system REPAIR ❑C1101111-CONNECT(REPAIR ❑VAPoA EXTRACTION WELL F � <br /> (TYPE Of PUMPI ❑N—❑n.* H.P. DEPTH PUMP{fT_PT- FIRST WATER LEVEL p <br /> ❑ow-af-stnvics WELL ❑OEonnmCAL WELL 7 IV BOIL{DR{,G V 3 C.N e <br /> ❑OeeraucT10N: <br /> INTENDED USE TYPE OP ELL CONSTRUCTION SPECIFHCAIIONs �1 A <br /> 11 INDUSTRIAL ❑OPENaOTTOM DIA.OF WELL EXCAVATION-414R--� pA.Of CO WMTORCA— p <br /> ❑DOMESTICIPAIVATE ❑GRAVEL PACR/MIE TV1E Of CAS11DmTEEIX'VC 1 Y DIA.Of WELL CASINO N I p <br /> ❑PUSMI UNICN'AL �❑DRIWN OEPIN Of GWVF SEAL �e, SPECIFICATIONAII& s <br /> ❑WJWAT10WmAG OTNFR CMUT SEAL INSTALLED by GMUT SMND NAME QyV <br /> ❑MOMTORINO GROUT SAL PUMPED.Itl♦- ❑Ll. .+ ,1 CONCRETE PEDESTAL SY DNLLER❑Y- E9N. S <br /> APPROX.01["H LOCKID N sX/ <br /> CNE{TEOSTOVE PIPE ,41.4 { <br /> PRSFOSFD CORSTI11X:110NIDNLUNO MEfNODt A1UD ROTARY AM 110fARY AVOFN CAsIE OTHER <br /> ��r��- 4���,t <br /> 1 NEWSY CERTIFY TI/AT 111AVE PREPARED THIS APPLICATION AND THAT TNS WORK WILL Se DONE M ACCORDANCE WIT"SµJOAOUIN COUNTY OIIONANCEG,STATE LAWS.AND RULES AND <br /> REOIMTIONS OF THE SAN JOA001"COUNTY.HOME OWNER OR LICENSED AOENVIO S U ATURE CERTYRS THE FOLLOW1NOt•1 CERTIFY THAT N THE PERFORMANCE OF 710 WORK FOR VWIICII <br /> TIM PERMIT m ISSUED,1 SHALL NOT EMPLOY PERSONS SMJECT TO WO!"AN'S COMPENSATION LAWS OF CALIFOINM.•CoNTRACTORY HIRING OR sU"OMRACTND SIGNATURE CERTIFIES <br /> Tllf FOLLOWIIDt -I CERTIFY THAT N TINS PERFORMANCE Of TOM WWW FOR VWHSCII 7II6 PERMIT IS ISSUED,1 MALL EMPLOY PERSONS SUBJECT TO WOPKMAN•S COMPENSATION LAWS OF <br /> CALIFORNIA•'/THE APPLICANT MUST CALL 34"CUM IN ADVANCS FOR ALL REQUIRES INRQTION{AT I1Nl1 M0114S4cl IE,Et.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> SIPPd X •. ICrI.v..R/u— P{•OYY�.LJa p� TM. //1(Aiyla y,Ln we. /0I;`Q't <br /> PLOT PLAN 914—N ft"IOM. •le <br /> /.NAMES OF <br /> ST11EEft OR IIOA01 SPAREST 10 OR scumuma TNOPERTY. ♦.LOCATION ST <br /> Of HOUSE SWAGE DISPOSAL eYEM 011 RIOIO{ED <br /> i. Tiff PR <br /> UTLINE OF TIRE PROPERTY,OMM DIMENSIONS AND NORTH OSECTION. EXPANSION Of SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTND AND PROPOSED S.LOCATION Of WELLS WITHIN 11AOIUS OF ONE IIUNDIIED NFTY FT. <br /> STAIR <br /> 137x15 HIOJrnI u <br /> O a z � <br /> H a: <br /> lY O <br /> J O tt <br /> SILO J ga J N <br /> a o V < o Q <br /> C U cr¢CL U <br /> O •i <br /> _ j <br /> In <br /> U <br /> N F=V v U y y . <br /> = a0 k=r <br /> o wt a a Z <br /> ^ N <br /> a� <br /> P <br /> ♦ <br /> DML � Z <br /> %o"ne 3ovuois A 139 Q <br /> .. A31TY <br /> ♦ ® LJ 1 W <br /> x a ..... I <br /> Y£0►5606 �,�,I . .. <br /> ovARTMe/T Dee oNLT <br /> AF.M.tNn A....w er �j'-J�1 'rnJ L,Q- OH. O• A... <br /> a..A b.Rw.RI..er DH. wMP HIw�SRO er oH. <br /> 0--dew IMq..I n Ilr DM. <br /> c«ww.l.: Set FtA515ftD Lanresj2Gi4 1e, -<. tk)avrQLaoi1 d4 l0 3C1 - <br /> ACCOtN11N0 ONtV: ADS FACS <br /> FE coats FEE INFO AMOUNT REWITED CIIECK//CAST/ RECEIVED my GATE PEWIIT/SERVICE RaoUE{i SLIMIER INVOICE <br /> O <br /> Pub.Heafth Serv.-Enviro.173(1/97) <br />