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APPLICATION FOR WELLIPUMP PERMIT ^ ,,.,SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIL,..MFi - ENVIRONMENTAL HEALTH DIVISION P.O. BOX 368, 304 EAST WEBER AVENUE, STOCK TION, CA SMI-386 .` 11091 463-3420 NOV i 2 199F NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM UATE 133UE3 ICmeplel8 In TrfBReBld SI j, . A MMAT ION 1911ERE BY MACE TO THE SAN JOAGUIN COUNTY Ton A MnM1T TO CONSTRUCT ANOIOO D18TALL THE'WOE n-CMREO.T1113 API'LICAIMIN M MAGQbL OQMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER S.I I IS.3 ALIO THE STANNPAnn9 OF SA4 JOAGI LIN CODNTY/MBUC 1¢nr nl AFRNCES.FNVIRONMF.NTAL HEALTH DIVISION, JOB AODRESOMR APNI_ 7�F, �L�/Y P Sn /(�[f CITI �TO p/1 nARCEI SITEIARII OWNEn'8 NAME_,4 (2 rr4� /A1�(/Sl�.ql Pio j7e/,AiGS AOOAESa /7sy1� F /\j/19i.0oS9 �/�Zc.�. RroNEI 41a Z&16 Z&16 CONTRACTOR—(a -w to-,tcak 11I LC�LL V\CL'1 -�{'L C AMIIERS ��T J IG`L C RHONE 17Jj—53 C�'-E•'ILLI SUM COMPACTOR �y I ILC Vt ADORERS V I t VAC ``L I. Loi(. TYPE OF WELL/PUMP: ❑ NFW WELL ❑ r1EPACF.MEM WFLL ❑ MONrtn PNR WEIL I ❑ OT14EM 11INSTALLATION ❑WELL SYSTEM nEPAIR 13CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑NPN❑ReSN N.P. DEPTH PIMP SET—FT. FIRST WATER LEVEL p ITYPE OF PVM% ,.,/ 1:1 our OP SERVICE WELL 13C OEOPIYMCA1.WELL I BOIL SOMNO 5- 0 ❑DESTRUCTION: INTENDED USE TYPE OF WE{y CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN SOtTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ MMF9TM:IPRIVATE ❑GRAVEL PACRIRRE TYPF OF CAIMMISTF.EU c DIA.OF WELL CASINO p ❑ PIBUC"UNKIPAL 0OOMVEN 1^ DEPTH OF GROUT SEAL SPECIFICATION RR �❑ IRGATIONIAG tJ UTNER �' YL y GROUT SEAL INSTALLED BY GROUT FRANC NAME E '.S BgMTONNO F' ORDUT SEAL P NIMM ❑Ww ON. CONCRETE PEDE8TAL SY DPLLER!❑Y- ON. 9 APINI DFPTH I O LOCKING CIDSTEH BOX/SIOVE PPE MS ,T �1 moroBm ODTRUCTION/ tuma METTSJD: MUO MTAID' AIR POTAPY AIICFR CABLE OTHER HELI AL/JG� V' 1 NERERY CERTIFY THAT I IIAVE PREPARED THIS MRJCATMIN AND THAT THE WORK WILL HE DONE IN ACCOIIOANCE MTN BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND nEOLMJITIONS OF THE SAN"AMIN COUNTY. HOME OWNER OR LICENSED AOF.W'S SIGNATURE CERTIFIES THE FOLLOWING!'I CERTIFY THAT IN THE PESFOPMAMCE OF TIIE WOM FOR WHICII \ THIB PERMIT 18 ISSUED.1$HALL NOT EMPLOY PERSONS SUBJECT t0 WORKMAN-5 COMPENRATOM LAWS Of CALIFORNIA.- COMPACTOR'S HIWNO OR KUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS RRMR IS ISSUED.I SHALL EMPLOY PEAMON9 SUBJECT TO WORKMAN'S COMFeM,TTGM LAWS OF CADFORN^�\�-�/� 7M MT MyRT A/y,.CZ US IN NCE FOR ALL REQUIRED IMSPECTMNS AT!P4 AMYSf. C(O�MPLE�TE(DRAWING AT LOWER AREA 1TOVIDE 1 91En./X Y L [FyL'-`__' �/�1• Tnl. �.J LCC F"CS L..GI�L:� 1 Rot FUR ID,.b Seel.(9eMa -Ie 1. NAMES Of STREETS ON ROADS NFARFST TO OR BOUNCING THE PNOMPITY. 4. LOCATION OF 14OURE 9f WAGE DISPOSAL SYSTEM OR PROPOSED T. OUTLINE OF THE PSOPERTY.OINNO DIMENSIONS AND"PON OINECTION. EXPANSION OF REWAOE DISPOSAL SYSTEMS. 3. DIMENSIONED OUITLIMB AND LOCATION Of ALL EXISTING AND PROPOSED S. LCCATroN OF`PALLS WITHIN RADIUS OF ONE HUND"D FIFTY R. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WALKS. ON THE TTOPERTY On ADJOINING PPOPEF Y, vvu DEPARTMENT USE ONLY nePlkMbn Aeeaelpl BY Dale Arw Oreul 9wPmeen Bl /'f/S91 O.b Owrnntlen IrwP�velle"n HY / Can.mn.le. �1�y\A('� (AIA 1weAAr // A enljA a �nLMGL ASI AAAml!FTT ACCOUNTING ONLY ,\ROI FACI AgIFI �^ PE CODES FEE INFO 1 AMOUNT REMITTED CHECXIICA811 R£CDVED SY DATE PERMITMEPVICE REQUEST NUIMBAR INVOICE C71 .00 b9 o3S I I 6 I Pub.Health Sam.-Enviro.173 13/967