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APPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SER g ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE. STMKTpK CAS 1209) 468-MO NON-REFUNDABLE PERM PIKES I YEAR f ROM DATE f3 UED APPLICATION IS HERE ByMADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCTA NDplate T�IE� IOFt INSTALL THE WOR(CKSCRIIIEO_TMS AMJCATION IS MACE IN COMp,1 JOAQUIN couNTY DEVEmpmwr TITLE,CHAYrrm$-1116.3 ANO TCHE STANDAMS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEiiVRCEB,EwwONMEMAL HEALTH MnIMON.��WVTTTI a. JOB ADOWSSOR APNI AAA 60�•/'i��L v)ulvl t��Q"�' CRY A�Gk tb'/J p{ p PARCEEL/9tZE/APNI OWNER-SHAME 'F.'`.t2 a 1K,J?�FC��lA -�e(1�'�"��2�`T�iT� AOOREes 1014 0tl0V.I.%ka St., �JbJX(-t -kA PNoNes 7-55.2212 CONTRACTOR I)CS•f AAVVIA� 0y)I�✓yy g $$ 51105 J� AooE�as 32 33 �1-Z�i�a,1A r�.". ue, �,— SUB CONTRACTOR ADORERS ?Um LV7p CA uco GS4-5549}y SNE, 06 -:fz+4p 5:iA TYPE OF WmLfvumP- ❑ NEW WELL ❑ REPSACEMENT mu MOMMORNO WELL r FY :out 0�Six ❑ oTriER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ Cmas-comwc-T REPAR ❑ VAPOFt EXTRACTION WELL (TYPE OF RIMP1 1313 m N.— mak NP_ DEPTH RUMP SET FT. FIRST WAT7<R LFVEL ❑ OUTOFSUIVICE WELL ❑ GEOPHYSICAL WELL r ❑ sok BORING t ❑DESTRUCTION• INTENDED USE TYPE OR Ir EU, CO"TRucnoM a>+ psCATIOMs ❑ INDUSTRIAL ❑Open BOTTOM DIA.OF WELL EXCAVATION '16 1✓Idqu I m -\;) DIA.OF CONOIUCTOR CASINO � ❑ OOME9TlCJmvATE W(GRAVEL PACR/BIZE TYPE OF CASIMG/8TL6(/T/G PV(,. DIA.OF WELL CASINOL�InL�I c LIIJM PUBCUNICIPAL ❑DESVEN OEPTH OF GROUT SEAL I�'-to 'F s'EdFRCtME-STAL f ❑ IRRIOATnNlAG ❑OTHER GROUT SEAL NRfALt®By Ink:6�'�,L7mnZ� OADUT B •�. \LJ MONRORINO ''JJ__ GROVT SEAL F UMPEM ❑Y.. ❑Ne CONCRET1911 pwLLtx Cl Y. P,-,. APPROX,DVITM .`Y•. _ SO +iD LOCRINO CMESTEII BGXUSTOVE RPE J 0—� PROPOSED COMSTRLICTIONIDAWNO METHODS MVD ROTARY AIR NOTARY AVOER \' CABLE OTHER- 1 HEWDY CERTIFY THAT I MAVE PREPARED THIS APPLICATION AMO THAT THE WORK WILL BE DONE M AccoMAMCE M?TTH SAM JOAOUN COUNTY ON"NANCES.BTAYE LAWS,AND RUUq.w REGULATIONS OF THE SAN JOAQUIN COUNTY. NOME OWNER OR UCENSED AGENT'S SIONATUII!CERT CS TME FOLLOIAI NO;y COMFY THAT IN THE PERFORMANCE of THE WOR[FOR MMIC THIS PEWIT IS ISSUED.I SMALL NOT E'MFlOY PERSONS 200JECY TO WOMMAN'S COwPWSATIOM LAWS or CAUFORN a_- COMTfLCTpR7 HWFIG OR SUeCONTR.CTNO SIGNATUM¢lEIMT1Fll THE FOLLOWING= 'I CERTIFY THAW 1N THE PMU'omAAmCE OF THE WORE PORI WHICH TMS R4PWr re ISSVED,I SMALL EMKOY PEROON3 SUBJECT To WOwwAM•S CorrorsanoN LAWS C CAUFOWAA.- TLi AORJCAMT MINT CALL y ypURSrr IPI AOVAMLC Q,�JFpR/1LL R[OWREYf rRMSyTp/Ns tAT�T2VS)Ar�D. COMPLETE ORAM11N0 AT LOWER AREA P{pVIDED, Sbrii°X r DT l R3 T10 .-J/b1( cT htiL VI�sR r D,e. by*48 8 Cavy. C w �"�ieT w �.sd-► 1. NAMES OF RREETS OR RapAOS NEAmffr TO OR BOUNONG THE FMIgRIY, s. LOCATION OF MOUSE SEWAOE DISPOSAL YYtTTEM OR Pnow)"D I. OUTLINE op THE PROPERTY,GMMG OIMENWNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIS008AL IYfTEMS. 7, DIMENSIOMEO OUTLINES ANO LOCATION OF.PLL EXISTING AND PRpPOsEo S. LOCATION OF WE1,LS WTTNtN RAOWu OF ONE MUMDREO FIFTY FT, STRUCTURES,INCLUDIMO COVERED AiOAS SUCH AS PATIOS,DW\MWAYS.ANO WALKS. ON THE PROPERTY OR OJOINING PROPERTY, 4 ►;+�. Rlvi�c�l k, �,`., �;........ d _ h..., �.9. 9 .......:...... , :... ........,......:......r.,....,,..,................ . ..............1...•..............12......1.................... . ... ............. .. .. .. ...................... ..........:...... .. .. .. .. ......... ..:.. ...:.. ... ..... ISS IDEPAI"4W Um ONLY pQ,IL�IN►f` LT "CD �'li rGNEIt� Appi..lLn A.�lad B. 2,3 &W42, ,DM. 113•2� 2 GMA"�1"n'P�4Dl11h7$ Ge.u1 lm"—OpR By. Date PLL p Inapactlam D-om.*.n"p—tl.r.S. Owe. Conxner4r, ACCOUNTIMO ONLY; AID/ -F -Cl CODES Fa IMM AASOUNT itswr Eb CHEC"ICAS" "Ctvm by DATE ►9MUISOMCE REDU"T NUMSIIIII INVOICE