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APPLI 'LGN?OR WELLIPUMP PE Ml I <br /> SAN JOAOUIN 'a <br /> OUNTY PUBLIC HEALTH SEAM ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388. 304 EAST WEBER AV34 0 E. STOCKTON. �+ `9a2f)1.988 <br /> D <br /> NON.REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DRTE ISSUE <br /> IC{IRPI{to in Tr4fintEl <br /> 6 OF SMT A MICUIN COUNTY M UC HEALTH SERVICES.ENVIRONMENTAL HEALTH DMBION. <br /> APRICATION IS FIEPE BY MADE TOrT�.CHAPTEP 4111$.3 AND THE SUNT'Y MR A PERMIT TANDARDS CONSTRUCT AryppR SJ6TALL THE WdI(DESCRIBED-THIS APFVCATION I6 MADE IN COMRIANCE - <br /> JOAOUIN COUNTY DEVELOPMENT I C PNiCEIW / <br /> IS cm SiOc -ID-+ <br /> f63• - pp //JJ <br /> /�'V PHONE! <br /> JOB ADDRESS"APNI APnI '' V 3 ADOPESB flAl� o.J Q[w7 JIAGnA-R �— <br /> / ST OT�Jp..UCl11221.0 -I PHONE/� 5 8 1 <br /> OWNER'S NAME UG D6M+F� I• - �.. ! 2 O ADDRESS (iS Nifa.ut".. <br /> J I.vC• PHONE/ <br /> CONTRACTOR SPEcrRuM �7(�c.FrLo LIC/ <br /> ADDRESS <br /> SUR CONTRACTOR <br /> MpNTTOPoNG WELL/ ❑ OTHEM1� <br /> ❑ REPLACEMENT WELL I] VAPOR ocr,.CTION WEU./ <br /> TYPE O ❑ NEW WELL SYSTEM REPAUI C] CROBBCONNECT REPAIR❑ INBTAlUT10N ❑ WELL FIRST WATER LEVEL <br /> DEPTH PUMP SET—FT. oA <br /> Nw❑RrRO BO ' <br /> (— <br /> H.P. �( - 10 150 <br /> yyY IL BORBNi <br /> ,TYPE OF MMPI ❑ OUT-O •SEMACE WELL ❑ GEOPHYSICAL WELL! / <br /> ❑DE6TINCTION: <br /> CONSTRUCTION{PECIFRCAD➢M{ DW OF CONDUCTOR CASMO <br /> ❑ <br /> INTENDED USE TYPE OF WELL <br /> OPEN BOTTOM dA.OF WELL EXCAVATION-- OUl Of WELL CASINO--- <br /> ❑ INDUSTRIAL TYPE OF CASINGMTFEL P —� <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACXIBG:E SPECIFICATION <br /> ❑ <br /> ❑ pUOUCIAIUNICiPAL DPoVEN DEPTH OF GROUT BELL GROUT BRAND NAME <br /> ❑OGROUT SEAL INSTALLEDBY—� <br /> Cl IRPoGATIIN/AG OTHER GROUT SEAL PUMPED: <br /> 2pyr ❑N^ CONCRETE P4DESTAL BY DRILLER:O Yr Ne <br /> ❑ MONROPoNG LOCKING CHEVER BOXMTOVE PIP£ <br /> AMROx.DEPTHAIR ROTARY AUGER CABU OTHER <br /> AIOPOBFD CON{T1IUCTIOMMPoWMO MET1100: MVO ROTARY <br /> HEREBV CERTIFY THAT I HAVE PREPARED TMB APPLICATION ANO THAT THE WOR%WILL BE DONE M ALCOPDANCE WTTN BM AADUM COUNTY ORDINANCES. STATE '.RUGS. AMD RULES <br /> THIS PERMR980186VED61.6HALL NOT EMROY PERSONS BUB.IECT TO WMIO•LAREi COMPFNBJLTroN OF CALA4 RNIA NCOTMMCTOTI MPoNO OR BVELD�NiiLACTINO SIONATVRE^_EiD <br /> THE FOLLOWING: 1 CERTIFY THATT CALLS�O�B IA N E�VANGE FORRALL REO m 1�11BFECTIOW AT RMI ABiYZ2_ COMPLEEE dV.VA16�ACT-TIDWFR MEA i'ILON/D�/EATWM LAN <br /> CAUFORWIA.• THE MFuc�,,�/ �/�, �� /)_ /_��r �. Y/ZZ L Q <br /> �,c,.^�.��%?%' y✓�9/a / �.�T� rn. �'/ //]'Syr.."'_ <br /> vTa� x �� ✓/ <br /> ROT MN Mk.,.SeMI Grab 'IP <br /> a. LOCATON Of TIOVBE SEWAGE DISPOSAL SYSTEM OR PfM]Po6ED <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUND"THE PROPERTY. �PNMN OF SEWAGE D,6 ISAL SYSTEMS. <br /> 2. OUTLINE OF THE PROPERTY•GMW DIMENSIONS AND NORTH dRECTIDN. t. '.OUTION Of WELLS VrtTHa RADIUS OF ONE HUNDRED FIFTY F <br /> J. DIMENSIONED OU NF6 AHD LOCATION OF ALL U'STRNG AND PROPOSED ON THF PROPERTY OR ADJCD M PROPERTY. <br /> STRUCTURES.MCLVDIM COVERED AREAS SUCH AS PATIOS.OIVEWAYS.AND WAIILB. <br /> 0 eq <br /> DEPARTMENT USE ONLY <br /> AoWlwlbn A� .PI.�BY <br /> D.I. <br /> PVmO 4+Pa'Oen BY Da. <br /> Olen ImprlbR ar D.R. <br /> Commsnc C C�,f/Lf <br /> FAC! <br /> ACCOUNTING ONLY: ND/ <br /> R CODU FTP INFO AMOUNT RSMI I ED CHECIIMAIH RECHVED BY <br /> GATE R9NBT1{FRVICE REGLROIT NUMBER INVOICE <br /> �z2 <br />