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APPLICATION FOR WELUPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete M 711ppestal APPLICATION IR IIERE BY MADE TO THE CAN JOAOUIN COUNTY FOR A PfnMIT TO CONSTRUCT ANOMM INSTALL INE MAK OESCR111E0.7108 APPLICATION IB MADE IN COMPLIANCE WITII BAN JGAOUIN COUNTY DEVELOPMENT TITLE.CCHAPTTE�R 9-1115.3 AND 111E BTANOARDB OF BAN JOACAnN COI�MQY PURVC IIEALTII BERVIIA,C�EB,EN V1110NMENFAL IIEAITII bMRION. JOB ADDRESSMR APN/ '12'q 1 Z { S�r `(JVWLA'Yf(.�� 31• CITY O 1 V 4A1by\ c, ` PA/ICFL BREIAPNI ..W.•N NAME 160-VJ-B- f- Fredtr(Z CLAIrkJl., AMlI1FaR•3S t 1 '>iTOQ�AIY 'fro `SSS g RwNE I��•ZSS' g�I coNRMtro11 C UA'0'—tw lsi'oylF J•SZO 3�`Z ?*I- 'M L o(d ADOW..aN bcn(L.�,&L -Cl G LicitPLANE I�I u•9'13-s 16 0 mus COMMCTOR MlMn&Q�u.iNg�41V., PU3ox 2'L 31 ADGIESN I2maV.t(1t0Cc�rl061%-ACuc1 X03$ 8b nwHEI9l�•erZ--SSI, II"7..LI TYPE OF WEtUMMP, ❑NEW WELL ❑REAACfMF.NT WELL ❑MONITONNO WEtt I ❑OTHER ❑O/RTALLATION ❑WELL RYSTFM nEPAtq ❑C1108N-CONVECT REPAIR ❑VAPOR EXTRACTION WFLL 0 J ❑N+er❑R•PW H.P. OPRH PIMP art FT. FIRM WATER LEVEL O HYPE OF MMPI �y �.L.❑0Vf-0E-aE1MVICE Witt ❑OF.Og1YRICAtWELL/ ❑ BOIL BORING 8 4L OEMRI/CTION: • "`w � Z (N — I L�1eI�� /V`�T�•�O U INTI ENDED USE IITS O CONSTR LION BP IONa Jim a• ,ca d �r A [IINOUSTRAt ❑OPEN NOrTOM DIA.OF WELL EXCAVATION IRA. � � INA.OF CONDU On CAVING a ❑DOMERTICMMVATE ❑OMVEL PACK/SIZE TYPE OF CA01NI/RIEFt/PVC ORA.OF WELL CARROT O ❑PU%UCAIUNICIPAL ❑bNVFN bEPTII OF TROUTBEAT 42tA4,t-E- bcfe, Q SPECIFICATION A ❑InMOAlMN/AO ❑OTI%q GROUT SEAL INMAIIED BY ORDI/T BRAND NAME AA&4 (,QM.tSt.l('- E ❑MG14TONNo OROI/F HEAL PNA AP:❑Y•• ❑N. CONCIIETE PEOESTAI SY DRILLER,Ely- CIN. s APPROX.DF./TH to"wo Clite?FR BOXMTOVE PIPE s PROPOSED CONITRUCHONIDNtUNO METHOD:MIND ROTARY AIR IIOTAM AUDEN j< CABLE 0/11E1% 114F BY CEnTIFY THAT I IIAVF PEPANw T14S AFPUCATION AND THAT 111E WORK WILL RE DONE IN ACCORDANCE'ART"8AN JOAOUIN COUNTY OnOINANCEe.ST Alt LAWS,AND MILES AND 11EOU AT10NS OF TIRE RAN JOAOUIN COUNTY.NOME OWNER OR LICENREO AnENT'R StONATUM.CETNK.B THE FOLLOWING:'1 CERTIFY THAT IN T11E FERFOMAANCE OF TIIE WORK FOR WIRCOI 1140 PEPMIT IR MRUED,1 SIIALL NOT EMPLOY PIPPONR"MCI TO WORKMAN'S COMPPNSATION LAWS OF CALIOPNIA,'COMMCTOq'81 INNO OR SUB-CONTRACi1NO RwNATUnE CEMIrIES TIO FOUOWINO: 't CERTIFY THAT IN 711E PERFORMANCE OF Ittf WO/SK FOR W INCH TMS PERMIT to 1RRUE0.1 aHAtl EMPLOY PERSONS SUBJECT TO WOMTAANY COMPENSATION LAWS OF CALWONR A►N1CANi WT=CAI"IM ADVANCt FOR LL NEOIRRED INSPSCiwNS AT 120111MJM2S.COMPLETE DRAWING AT(OWER AREA I'IKO DED. Nte..•A X ..� r�1-: . 6 �5 TIS. . drat •- DN. tv I`D 9 rG PLOT PUN IDr.w le Peet+1 N••I• le 1.NAMES OF 8TIEFT8 OR ROAD*NEAREST TO OR NOUNOINO TIIE PROPtVV Y. 4.LOCATION OF IwUSE SEWAGE MRPOOAL NYMEM On PROPOSED 2.OUTLINE OF T/¢1rwPERTY,GIVING ONAINVIONS AND NOMN MRECm". EXPANMOII OF BEWAOE CORPORAL 8YMEM0. 3.OWF RRONED OUTLINES AND LOCATION OF ALL EXiWt*M AND PROPOSED S.LOCATION OF WELLS Wr"WN RADON OF ONE HUNCOIFO FIFTY FT. 8TRUCTUW9,IMCUMINO COVERED AREAS NUCR AS PATIbs,DRIVEWAYS,AND WALKS. ON TIIE P10PERTY OR ADJOINIMT PROPERTY. :. . s. ... .....:................... ................................:... . ' �...I/�/� OF/MTMENT USE ONLY Aeene.tleR AeeeeeeM BT I N `fT�'C tl'N•N DNR O d�'- 1.U Mw _ G.eot Anv+eleR Nr o•I• P.-e Ime+nueR Nr o.R D«ul.�tlee 1-.n.e<ta.Rr �_ D•tw � � __ Cemm�, ACCOUNTING ONLY: MDI TACT PE CODES FEEINFO AMOUNT REMITTED CIIECKlm ASH RECEIVED NY DATE P9PAIT/SFRVICE REQUEST NLWNM INVOICE 35w, —� 61 ? Pub 498Ith Sety.-Enviro.473(1/97)