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4;, <br /> ' ¢ APPLICATION FOR WEWPUMP PERMIT ^ ' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f <br /> C ENVIRONMENTAL HEALTH DIVISION <br /> P0 80X 388,304 EAST WEBER AVENUE.STOCI(TON.CA VMI- ea <br /> h ✓ + (209) 488 3420 <br /> ' NOR REFUNOAKE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> 11 IH:empS@IF In TFIpWatal <br /> AMICATION 191 ERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PEAFItf TO CONSTRHICT ANDAR WOTAtL THE"W DERCRMfo Ties APPUCATiopt IM MADE M COMPIJANCE WITH FAN <br /> JO,{IOIIIN COUNTY DEVELOPMENT jrnc CHAPTER 0 11 T 6 S AND TIIE STANDARDS OF MAN JOAOUIN COUNTY PUBLIC IISALTIL SERVICES LHUIRONMENTAL HEALTH DIVISION ' <br /> JOS AOOREBSIOR APNF ,/r I � � �� � �� J CTI J / <br /> I r FARCtt SLE/APNI <br /> OWNTrta NAAE r �/! [ rj ADDRESS f`. /'_�y `JC!�L/sf`J/-A r l,�r// PHONEI Y' <br /> ADDREef. ; r LICE P40HE0 <br /> IRIS CONTRACTOR r^�r (, / r I ( ADDIIESM LICI (HONE <br /> NPE OF WELtMM ❑ERW WELL ❑REPLACEMENT WELL 11MaNTTanum WELL/ T ❑OTI?,IL <br /> 13 INSTALLATION 0 WELL SYSTEM REPAIR ❑Cnas"ONNECT REPAIR ❑VAPOR EXTRACTION WELL E J <br /> (TYPE OF PUMR <br /> 13N—11Fzlor H P Df PTH PUMP BET FT FWuT WATER LET.EVd <br />' <br /> 1:1 OUT-OT BFRNCE WELL 11 Pf01`HY6ICAL WfLL■ I�BOHI RDRNIO <br /> ❑DEBTRUCTIOIP <br /> NIENDEO USE TTMOF WELL CONSTpUC NON SPECIfICATIONS A <br /> ©INDUSTRIAL ❑OPEN MOTTOM OIA OF wELL EXCAVATION DIA of COHOUCTOR CASBKI 0 <br />' ❑DOMEMTICIRWVATE Q ORAVEL PACI(MIZE TYPE OF CAp1NO/BTEELIfNC DIA OF WELL CAStNO. 1 0 <br /> WMUG <br /> ❑ MUNICe'AL ❑DRvLN DETRH OF GROUT REAL_")r / I/l!?! 41 !C,/4C—A-- R <br /> ❑MaYoATKINIAO ❑OTHER GROUT SEAL INSTALLED DYY / ' �/,IL=n!C r` 0RR0VI IRAND NAME 6#4. <br /> ❑MOWTOMW /n R OROUTRTAIPUMPFn Lry yr ❑H. CONCRETEPEDESTALSYDRU.M13Y. ON. is <br /> 1 APPROII DOTH ./r r i.!1/ v I/~ �-�/ _J­3"W LOWN0 cHESTEn eoxArTovE PIPE 4 j <br /> PROPOSED CONRTIMCTION/M tJUMO METHOD MUD ROTAS AIR nOTARY AVOER—,.15---CABLE OTHER_ t <br /> I HE4EBY CERTIFY THAT I IRAVE PREPARED TIES APPLICATION AND THAT THE WOR(WILL RE DONE IN ACCORDANCE WITH MAH JOAQUIN COUNTY ORDINANCES @TATE LAWS AND RULES AND <br /> 11[OLRATIONR OF THE SAN JOAOUIN COtN IV NOME OWNEn OR LICENSED AGENT S RHOIdATURE CERTWIE@ TIRE POLLOYWNO I CERTIFY 7HAT IN THE PETYORMANCE OF THE WOR(TDR WAMCII <br /> THIS PERMIT is ISSUED i SHALL NOT tMPLaY PER90I49 SUBJECT TO WOMKMAN S COMPENSATION LAWS OF CALWOPO4A CONTRACTOR @ tWFWM OM SUB{OWMACTINa M"AIVRE CERTIFIES <br /> 1 THE FOLLO"'M I CERHFY THAT IN TILE PERFORMANCE OF THE VIDIH FOR WMICH TWO PERMIT IS f@SUED I OHM EMPLOY FfRPONS BUSACT TO WORMAWS COMPENSATION LAYW OP <br /> CAUFORINA THE APKICANT MUST CALL 2111o7 IH ADVANCE FOR AU.MEOIARED INSPECTIONS Al'12061400-2422 COMPLETE ORA%MM AT LOWER AREA P OVIDED <br /> ..1 <br /> Siad X ~� G"�J:...IITIII._� <br /> PLOT PLAN rM—t.S..I.1 S.«. Re f <br /> 1' NAME!OF eTREETF OR ROADS NEAREBT TO OR PROPERTY BOUNDING THE PPERTY 4 LION <br /> OCATOF HOUSE MEWAaE IJI6POSAL SYSTEM OR ROPOBED 2 OUTLINE OF THE PROPERTY OMM DeMENSIONS AND NORTH DIRECTION EXPANSION of REwAaf DISPORAL SYSTEMS <br /> 3 OMAENSOHED OUTUN99 AND LOCATION OF ALL EXH TNn1 AND PROPOSED M LOCATION OF WE114 WITHIN RADIUS OF ONE HUHOhfo F*TY FT <br /> STRUCTURER INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYR AND WALK@ ON THE PROPEMY OR ADJOWINO PROPM" <br /> 1 = � <br /> PAYMENT- <br /> FES <br /> A 4 k - <br /> NMENT <br /> 1 F'ES 2,3 1999< v <br /> IAN JOAQUIN(`.OV " <br /> < v ENVIRONMENT L H ,E?M3rph , <br /> DEPARTMENT USE ONLY <br /> APPe.«l.n A...pt.d SY ZK r <br /> A,•.Y -/ 0.5 ` 1 <br /> "P..It—BT D«• P_In.•nlbn MT <br /> bwlni.N.n In.P•ollw.ET D«• �'H, <br /> P ! — 1 F7n+ I 1 r�.0? p v`f <br /> r rir ��Lti'[- ��lOiptrT 1�e r:T f: G <br /> ' <br /> ---I.ONLY ALO/ <br /> e' �1 C� <br /> PE CODF1 FEE INFO AMOUNT RENMTTEo C/HECKRA:Ail1 RFCOYED■Y DATEremitSERV10E REOUEST NUM@ IIfY010E '� <br /> Ii <br /> 'pk I <br /> Y Pub Heetth S@rV ErrAro 173{3186) <` t T <br /> dowL <br />