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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O,SX 388,304 EAST WEBER AVENUE,STOCKTON,CA i W <br /> (209)409.3420 <br /> 1101•REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> AMICATN gN IR INnF MY MADE TO TIME RAN JOAOUM COUNTY FOR A Io"Rrou f M TI(pReflll <br /> JOAOUCOUNTY OEVELORNENT TOM CNATER 9.1115.3 AND TIME STANDARDS OF RAN JOAOUN COUNTY PRIG 0FW DIS CRI ED,7ICES.f8 AlntC4MM ENV111ONANNTAI S A f) IDM�N IANC*WTIII RAN <br /> JOR ADp11ESRIOR AR '/(� <br /> IJJ� w• ['(� f' `lb , CIT-0.�(-)(+�,on PAM1CFt RIFE/APNI <br /> OMTRn'S NM1E�[�C�.LJU f IJ I� 1! AnIMERR 1 3 VQ W • WC' <br /> nbNE 1� J ( Sf I D Ua-1520 <br /> CONTRACTOR jf�lX1K� lT'Pe Cnl 1/•/1/��nn Tlll 1"(^AnfM1f RR <br /> /i r T —8 O <br /> 0 3 w n{L�Ai-1 b ZZ y <br /> Z ProNE J gS <br /> RVR CONTRACTOR ADMNSP. AK.YN17 <br /> Vit; F /lllrclorlF,ppc uC. �1R�z z RIo l <br /> TYPE OF YYELANJMR ❑NEW vvm ❑IIERACEMENT WELL ❑Mowonwo wEtt• Lq OiINR a 1�fln h0 <br /> ❑MSTALLATION ❑WELL SYSTEM REPAIR ❑COOR&CONNECT REPAIR ❑VAPOR EXTRACTION WELL <br /> (TYPE OF R/Mpi OEr• <br /> ❑N—❑n_.k N.P. a <br /> TII NMP EFf�R, "MIT WATER IEVEt <br /> O <br /> OER71KK:iroN: <br /> ❑OVT-OrRFnVIr,E will ❑OEpnrvACAL WELL J 94 SDR folfflo Z <br /> R <br /> INIFNOEO UfE ITP*OF WELL CONS IRVCIION fPECNICA ZION{ _ <br /> ❑INDURIRIAI ❑OPEN BOTTOM A <br /> DIA,OF WEtt EXCAVATION /.J Z IRA,of COWX)CTOR CAMMI__� <br /> ❑nOMFSTICfTTIVATE ❑ORAVFI,PACK/RDE O <br /> TVPF Or rARNIOIRI fit/1.1If: DIA.OF WRI CASoKf N R <br /> ClruftlC/R/I1NN:Irnl ❑nlll/rN —I n <br /> nFPillnr(lrol/i CPA t�-E'7�� RPECO1CAlION .�E <br /> ❑IDom Tom MQ ❑OTINq OROUT RFAt MSTAIAFO MY GROW MIAND NAME I 6 J .M 11R <br /> ®MOMTORINp 11�C7 <br /> APP <br /> OnnIT lFAI.PIIMPFO:❑V« ®N. p CONCIETE PEDESTAL RY OIRLtRpI V« ❑NP S <br /> PROPOS DEPTH LoCKNM CINSftn SownevE rww V/. <br /> S <br /> PROPOSED CONST11tbRpN/DISLUNO METHOD:MUD ROTARY AM VOTARY AIMER CARIE1� <br /> prrlEn �?Pe /���¢ <br /> I IIE•NRV CERTIFY TIIAr I IIAVE PREPARED TIKE APRICATION ANn T/IAT 711E L111W Will RF DONE M ACCOIK/ANCf WAIN SAN JOA"COUNTY Or4XNANCES.STATE UWR,AND RULES ANp <br /> MNOLRATIONR OF TIN RAN JOAOUM COUNTY.HOME OwHFn On tICENRFD AnENT•!RMNATI)nf CERINNS TMH roLLOWINO:•1 CERTIFY iHAi M THE ITWOTMJANCE OF TIN WOPK FOR WIRCII <br /> iIOR RRt71T M ISSUED,1 fllAll NOT EMROY PERSONS RI/RJECT TO WORKMAN'S COMPENSATION tAws or CALKORNIA,•CONTRACTOR-O IIIIENO on RVR.CpNTgACTRM SMNATIIRF CETD/ES <br /> TIN FOLLOWING: •I CERTIFY i11AT IN TIN PERFORMANCE OF TIN WOIK Fon V11111Ci1 TMS TEIIMIT IR IffVFD,I MIAIt FMPtOY I'ERfONS MNIJFCT TO WO ONFRAC M11 SKI NATION LAW!OF <br /> CALIFORNIA.• THE APRICANT MUTT CALL 74 HOURS IN ADVANCE FOR ALL REOUREO INSPECTIONS At 17001•Hyl!!,COL4rMf DRAWING AT LOWER AREA PROVIDED, <br /> IL <br /> W"-wx /AIL ) !A• l.J TM. S44FF GPD/o 5. 0.1. <br /> ROT PILAR ffh—I.f.J.l Re.l• •t. <br /> 1. NAMFR Or ffRFEtS OR ROADS NFNIF,fT TO On ROI/NONKI TIN emrfrnrV. <br /> O 4,LOCATbN OF IroVRF SEWAGE plfTgSµSYRIrM OR ITYIMR[n <br /> S. UTtME OF lIN PROPERTY.ONMG OWF,NRIONS AND NOTA DW..CTIoN, EXPANSION OF SEWAGE WAGEDISPOAL SYSEMS, <br /> STRUCTURES.�.I1/MFNSbNED OIRLM N AND LOCATION OF All E%ISf1PM ANO Foopo RED T <br /> S.LOCATION OF WELLS WRMN MONS I ONE INNODEO TNTV STRUCTURES.f/CLUOMO COVERED AREAS RUC//AS PATIOS.DRIVEWAYS.AIR/WAIXf, ON TIME PRIMPITY OR ADJOINING PROPERTY. <br /> W0aK P/c,Iry <br /> QC1 D 2S 0c4ober lc6b <br /> ........... . '...:.... <br /> eFrARrMENr vRE plttr /J/� <br /> APPS..Kw A..«1M ST D•I. /V 7 A— <br /> o.«R <br /> nwln.Ill.....n..+0en Rr oM• <br /> ACCOVNTINO ONIr: AID/ FACI <br /> ►E CODES FEE INTO AM"T REMITTED CIN /CAfII 1 RECDvlo SY DATE PETIMIT/Sr1IVMCE REQUEST Ntx"M INVOICE <br /> Pub.Heegh Serv.-Eoviro.173(3/96) <br />