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'°PLICATION FOR WELUPUMP PERMrrj-!,:rj <br /> SAN,`,aOUIN COUNTY PUBLIC HEALTH SERA ,. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 r R <br /> G t <br /> /51P1JC _ `jeV� at�t. , <br /> - - _ ROR•REFURDABLE PERMIT EGM <br /> XPIRES 1YEAR FROM DATE ISSUED , <br /> - Ic.Elpl.n M Tr�Renl J <br /> APPLICATION IN HERE BY IAAOE TO THE SAN MAOMN COUNTY FOR A MANNT TO CONMINCT ANDAM MWALL THE WON(OFMRMED.TINS APPLICA,,N N MAO,M COMPLLANCE WRN SAN <br /> JOAOOM AUNTY OE °,,,ENT TRLE.CHAPTER 5-1115.3 AND THE STAMAIOS OF SAN MAOUN COUNTY PUBLIC IEALTN SERVICES.ENVIRM"IENTAL"EALTH OMSION. <br /> JOS AIIOIEeNNR APNFSC✓PiJ"n CV.W� CT' �It 1 E LF�Ii Y PARCEL SNF/ARIF .,�` <br /> .. q.vrErtM NAMELnG'L .. . tlt0 - ADMaes /to�?—' '8i �% PRONES <br /> ` /�/��.f <br /> COMMCTOR <br /> J TJ 7 6ED&n1Jtleo/ mam)TAL : JC, ADDIEM �1V* A-W�IJVR LN 651)ZZ-rNONEE 7 1004 <br /> sisIS rL✓s s. -�r�(R�O k... ,Q , AeM... ��'`�6'•/3W r C, \ PHDN,Fsz y- 09p <br /> _ TYPE OF WLLL.R/AN: ❑ NEW WEu ❑ REFLAeerrENr wEu '"O ❑ MONNORMO wEIL F ❑ OTHER <br /> ❑ MBfAWT1ON ❑WELL SYBfEM REFMR ❑ CROSSCONNECTREFAM ❑ VNOIU EXTRACTION WELL F <br /> ❑Nw❑FAFY, N.P. i vErr"PUMP SET_". FIRST WATER LEVEL 0 <br /> RYIE OF PUMFI �� Q . <br /> ❑ OVT-0E-SERVICE WELL ❑ OEORRMCAL WELL I { BOX NORMO_ N QC. <br /> ❑DESTR1CIbM: d` . <br /> LNIENDED LIE TYPE OF WELL COMlTRUCTNN%PKOiCATM�IIN! • 1/� A <br /> ❑ INWSf1{AL ❑ SO <br /> OrENTTOM MA.MWELLEXCAVAMN 2/N. M.OF CONDUCTOKCASMO AJA O <br /> ❑ UOMEsrRJROVAIE ❑ORAVELPACNOE TYPE OFCASMGMTEEtRVC /Jw MA.OF WELLCASMO Z /.J , 0 <br /> ❑ Mnmx AL1INICNA ❑OT/EN DEPTH OF GROUT SEM �iNTI1.-�- -SPSC ATNJM ,.�J�j. .r-� 4 R <br /> ❑rn/RROSOANXMIAO - ❑OTHER . .-. _ GROHT SEK MSTNLIED SY Fly OROM BRAND NAME / 141VV Day E <br /> {S MOMTONNO OROHF SEAL PINNED: ❑Y. LIC CONCRETE PEDESTAL NY ORRIM-❑Y- ONe s <br /> APPRO%.OBTH�-- r , LOCKMO CNENTF11 S0%TOVE rWE <br /> FRBMSW CONSTRVCl10NIDNWNO METIOD: MUD ROTARY AN ROTARY AMEN CABLE OTHM--V-- <br /> I HE•ESY CFHTNY TNAT I NAVE PREPAPED TMS APPLMAT/ON AND THAT THE WORK WOL BE DON,M ACCOROAHCE WITH SAN"AOM COUNTY OROMANCES.STATE LAWS.AND AULES AND , <br /> REOMATONS OF THE SAN MAOUM COUNTY. NOME OWNER OR L/CENWO AOENTV WMATURE CEIONIEB 111E MLLDWMp:'L CERTIFY TMAT M THE FEFMO ANM OF TNT WORK FOR WMCN <br /> MS PERMN M NNUEO.I SNALL NOT EMPLOY PERSONS SVSJ TO WOMUIAN'S OOMRNNATIDN LAM OF CAURORMA.' CONTAACTOWO NNSNO OR{U{-COMRACTRIO KONATVRE CFRTIFIFf <br /> THE FOLLMMNO: -1 CEMIFY THAT ONTHE FERFOMAANCE OF TNF WORK FOR WNCH DIN PEMET N NMIEO.1 SHALL EMPLOY RRSONS NUBLECT TO WMEKAtW&COMFENSAMN LAWN O. <br /> CALIFORNIA' THE ARIKAMT MUST W FO <br /> MUSS ILOVNN:{ R ALL 11EONR® NRC0.1 <br /> RTIONS AT TE0014S2{. COMPLETE OMWMO AT LOWER MR <br /> AREA OVOED. <br /> eN.aX�i�a- i�,crTN. I��T04-06-99 <br /> V PLOT RAN W.ro Ba.I.I NeH. 'm <br /> 1. RM1EN OF STIEEfS OR ROADS NEAREST TO OR BMNIOINO TIRE"I PENTY. t. LOCATgN Oi MOUSE SEWAGE McP'MK SYSTEM Ml Pro1pBED <br /> S. oUrUNE OF TIRE WKNR RY.OLVEIG OIRAAEFlMM AND NONfII OVER EXPANKON of SEWAGE DISPOSAL SYSTIM". <br /> 3. ONAERNONED OUTLINES NLD LOCATRAN OF ALL OOBTENT ANT/"MORD {. IDCAi1ON OF M7:11N IIRrIeM MOAN OF ONS.MUNIIREO fFTY R. i. <br /> SIRUCPJ"M{ICLUDOM COVERED AREA$N1C11 AS PATUM ONVEWAYS.MD WALKS. ON TILE fIlOPE1IfT OR ROMBERG PROPERTY. <br /> 1 we any <br /> 1f} M.SoH Ao wtW By L/ <br /> a..A Irreaellen N. on. rU..ro Bl.s.ell.n BI Dn. <br /> Da,nnll.n BT D•'• <br /> t.nun.A.: <br /> ACCOMMO ONLY: AIRF FACS <br /> I] R tOOFI LNO AMOUNT NEASTTFD tNECIVICAIN RECBVEO{Y DATE P[PRNTAN S REOUFJT NVAN61 INVOICE <br /> 17- 117- 104 0 y <br /> w, Saw wFow <br /> �. Pub HeBNh Serv.-EnvirD.173(1/97) w <br />