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APPLICATION FOR 1MELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> P 0 ROX 388, 446 N.SAM JOAQUIN ST, STOCKTOM.CA 96201.388 <br /> at as-um J U L 171995 <br /> no*m l@Auf S001ST EX n 1 PEAS MV OATS ISSUED ,STH <br /> rommom it TRIN/isW ANDIOR INSTALLTHEWw�itIRH <br /> APPIJCATON S NEIE N MAGE TDTHE SAN <br /> eHAPTER&111COUNTY Tr1E tTMOAl1oiOF QM Aa!!1 tolNtlr wMJc f1EALTN tai <br /> JOMxMI COUNTY DEVELOPMENT / <br /> Cm ¢L1 C � PA11C�IWAPN, <br /> JOS Atii� �_�7'a'n_�_ AD Al ��iYY '� l/!►J!!7' uPHONE 0— <br /> AA' <br /> -J��ebl ME ADDRESS�Obi�. _PHONE °�y <br /> sus coNTRHAc'TLTR . <br /> CIA- <br /> Type OP WB Lfflm : ❑ NEw WELL ❑mpua Me+T WELL ❑ MDNRrDRwo WELL, O D»-at <br /> ❑ wsTAwLTaN ❑WELL sysnu P"AML ❑ cros&cow&cT REPAML ❑VAPOR OtTRACTLON WELL, <br /> Cl N..❑R4* HP. DEPTH PIRMP SET RR. FIRST WATER LEVEL. O <br /> (TYPE OF PIMP) , <br /> Cl ounoPL.eewlce WELL ❑aEowHrsRCAL <br /> wELl, ❑ sal DORMRRo <br /> A <br /> GES <br /> am= --TmopvpaL <br /> �D f I <br /> ❑wxxm"AL ❑OFEN BOTTOM OLA.OF WELL EXCAVATION O 01A.OF COPWUGTOn CASING O <br /> ❑pOIIESTICJPRMVATE ❑OMVEL PACICAIQE TYPE OF CAV-IUSTEELIPYC - DU1.OF WELL.CASINO <br /> ❑ASUTJMLMSCSAL ❑DIMVEN DEPTH OF OROUT SEAL S <br /> 13MMOILTIOWAO 13OTHER GROUT SEAL OWTALL60 SY ORDIR MAND NAM -" <br /> _ GROUT SEAL PVMPED:❑Ya ❑Ne CONCRETE PEDESTAL BY DPILLFIr❑Ya ❑Ne S <br /> APPIOX.O/TN +� LACKI-KW CHESTER SOXMOVE 1}R S <br /> MppS00 Mffno&. MLO ROTARY AIR ROTARY 111EOTS <br /> 1 HERS/CNITLFY THAT 1 HAVE PREPARPM THIS APPLICATION AND THAT THE WORK MALL M DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND MAN AND O <br /> RTAULATIONi OF THE SAN JOAOLIIN COUNTY. HOME OWNSH OR LIC000 AOLNT'f SIONATURE CERnFM THE FOLLOMMO:-1 CERTIFY THAT IN THE PETM°ORMANCE OF THE WORK FOR WHICH <br /> THS PEFAMT S NSUED.1 SHALL NOT EMPLOY PElELOIS SUBJECT TO WOI�IAWS COMMSNAMN LAWS OF CALIFOIMNA.' CONTRACTOR'S I WANO OR 004- TRACTMO SKHNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PSMAOWSANCE OF THE WORK MR WHICH THIS PLMMW S"M W-1 WNL EINPLOY PERSONS SUS.IECT TO VMFAW JM COMPSMATON LAWS OF <br /> CALM -MSA.' THE MPNCANT MUST CALL 26 HOURS M ADVANCE FOR ALL"SQUIRED INNMCfOMB AT 0044 400443=. COMMETE ORAWINO AT LOWER AREA PROVIDED- <br /> ..».X TRIM �-�bl� <br /> PLOT RAN Mnw a Salo i.r. -a <br /> T. NAMN OF STREETS OR ROADS NEAREST TO OR 20UIMM THE PRIOPMTY. 4. KIPANSIO OF HOUSE SENIAGE SYSAL sYaTs4 OR PROPOSED <br /> 2. OUTLAW OF TRE PROPERTY.dVINO OMEdSONS AND NORTH DIRECTION. EXPANMDN OF WILLS <br /> THINRADISPOSAL IS OF O i. <br /> 3. DMBISDIED OURItSS AND LOCATION OF ALL WITINO AID PROPOSED S. LOCATION OF MARLS WTTHIN RApUi OF ONE HUNDRED FIFTY FT. <br /> STRICTUIEI,69MUD/i0 COMM AREAS SUCH AS FXTROK ONVEWAYS,AND WALKS. ON THE PRDPIRTY OR Aoicom NO PRIOPRRTY. <br /> :.. <br /> .......... .............4............. ....:............:................:. <br /> ....................c......>.. <br /> - 1 <br /> %.......:.......:............::......:.............:.... <br /> . ...:.....:...........:.....4.. <br /> ..:......::......:.....:.... <br /> ; <br /> .......:......r ...4......;... <br /> .......... <br /> :.4.. <br /> .............:.....................i......:......0......%......n..............................)..... � ...p......:......n......:......n......:......4......�......C......�...... <br /> Owomm IT Um ONLY 71 <br /> APP6Mbn AraPtd BY— <br /> OnPA hrPalMn IM Don PUMP M D�eP <br /> 1 17 <br /> Daemodon InPD.a <br /> camm.w�e <br /> AOOOIMAN OIM.Y AIM FAC, <br /> M 00000 me" AMOMIT I01191"T00 CiOCKOICAMI RSOSVii SY DATO I PIRMRA1SIVICE 11001—T NIMINSI N&VM <br /> v ov 5,oeoo <br />