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APPLICATION FOR WELLIPUMP PERMIT <br /> • k,-)IN JOAQUIN COUNTY PUBLIC HEALTH SERVIC <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 448 N.SAN JOAQUIN ST,STOCKTON,CA 95201-388 <br /> 12091 4883420 1 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED <br /> (GEplotB M TFlphett) <br /> AMUCATR N IB HEM SY MADE TO THE PAN MACHIN COUNTY FOR A PERMIT TO CONSTRUCT ANDXIR MUM THE"W DEWBRIM.THIS APPLICATION IB MADE IN COMPLIANCE WTI PAN <br /> JOAWIN COUNTY OEVFLORAEM MM CHADFAB.1115.3 AO THE STANDARDS OF BAN MAWIN COUNTY MIMIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DINS OR. <br /> .POS ADDREPBmR ASND cm Tracy PARCEL PRNARM <br /> OWNEP'PNAMEHWV 31 Eigbt Qf W y ADMIEPe16NEI <br /> CONTRACTOR V&W Drilling ADoMUNP.O. Box 51 , LICA FDoNE 01707)374-2575 <br /> SUSCONTMCTOP AOOIESB'•"�`�F w �1 LECS HHO E <br /> TYPE OFWELL/PUMP' ❑Nm WELL ❑REPLACEMENT WF4 ®MONROPoNO VrELL I WCJ' ❑OTHER <br /> ❑INSTALATION ❑WELL SYSTEM"PNR ❑CRJSeCOHNECT REPAIR ❑VAPOR EXTMCTIOH WELL I J, <br /> ❑N—El RUHr H.P. DMr.R1MPMT_R, RPPT WATER LEVEL D <br /> OYR OF Umm <br /> ❑OUTOFAEIIVILE WELL ❑OFORrvBICµWELL ❑ BOB.BOPoND B <br /> ❑OEPTRUCTbN: <br /> INTENDED VtE TYFE OF WELL CONST DON SPECMCAHONt <br /> ❑INDUSTRIAL F❑�1 OPEN BOTTOM DIA.OFWELLEXOAVATION R_S' MOA.OF CONDUCTOR CAMND <br /> ❑WR <br /> MESTICMVATE WOMVELPACKIBRE HB TVROFCAMNONITEEUPVC 40PVC.. MKOFW'ELLCAMNO 211 D <br /> ❑RIBLICIMUNKIPAL ❑.FUWN OEPTHOFMbUTSEµ n_4' SFECIRCATION A <br /> ❑BUSUOUOMAO ❑OTHER GROUT SEAL INSTALLED By T r i In i m i ng DRouTBwroNAMCemnetq/4$ Bent E <br /> M MONITORING OROVi PEµPIMPED.134y. OM, CONCRUEPEDESTALBCVYOMLLERYr QNe S <br /> AHNVUL CERN 9n1 LOCKING CHESTER SCUMTOVE RIF P <br /> PROPOSED CONSOMMNNRWNO METHOD: MUD ROTARY AIR MTARV AUOPR1� CAME OTHER <br /> I HESEBY CERTB'THAT I HAVE PREPARED THIS APPLICATION AHO THAT THE WqW,MILL BE DONE IN ACCORDANCE MN SAN MALUM COUNTY ORDINANCES,BIATE LAWS.AND RUDER AND <br /> REOUATONB OF THE BAN MAWIH COUNTY.HOME DINNER OP LICENSED AGENT-8 SbNATURE CERTIRES THE FOLLOW'INO:'I CERTIFY THAT IN THE PERFORMANCE OF THE YAR(FOR WHICH <br /> THIS PERMR IS ISSUED,I MAU NOT EMPLOY IIPONBOVBIECTTOWO AN'SCOMRNSATNIAWPOFCAUFOMIA.'CONFRACTOR'BORNO ORNBCOMMCTINO MONATPE CERTIFIED <br /> THE FOLLOWING: '1 CERTIFY THAT M THE LINA A.OF THE WORL FOR WHICH THIS KRAU IB ISSUED.I SHALL EMPLOY PERSONS PVYEM TO WdtIMAN'S COMPFNSATON NWB OF <br /> CMIMMI/A/��FR APPLICANT STC B,(HUN IN ADVANCE FOR ALL REOU S INtFR'P,Q1NB AT IEOtI W-fLtB.COMPETE MMWMG AT LOWER AREA PPo DED. <br /> BIPM X l A l P /1��1 F /20CcA"A l A, On- <br /> OF RAN BR.v,I.BVNI DUI. 3 Y •I. ,w ' <br /> 1. NAMES OF STREETS OR RUSSIA NEAREST TO OR SOVNOMO THE FOPERTY. 4. LOCATION OF MUM SEWAGE DISPOSAL SYSTEM OR ROPoSEO <br /> E. OWUNE OF THE PROPERTY,OMNO MMENSION8 AND NOUN DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AO LOCATION OF ALL EXISTING AND MOMSED S.LOCATION OF MULS W'NMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,ONVEWAYS,AND WALKS. ON THE RUFEMY OR ADMININO PROPERTY. <br /> SEE ATTACHED MAP <br /> R ECEIVEr) <br /> [� I7 ' h r' <br /> SARI 1 <br /> BBNRMIM Wt ONIr 'yI A'41 <br /> ApgN.tlen Awy1M BY d1. 1'' i '�� Mr I <br /> G,FN ILIUM—81 ON. IS—P I. tlm BY D.I. <br /> Dslrunlen Irvp.nlm BY GIS <br /> Demmml.: GGrL:Tlz s C-nTQ2cbme44:: 1�9�--loSV—b15� <br /> A...0 RNG ONLY: AIDE FAC. <br /> R CODES FEE INFO AMOUNT MMUTFD CHECUOAM RECEIVED BY DATE FOMPTMERWCE REQUEST NUMBER INVOICE <br /> 35D <br /> 093J5 WAON lu X12 1 <br />