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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES 0 p-Y ENVIRONMENTAL HEALTH DIVISION V r� P.O.BOX 988. 04 9EAST WEBER AVENUE,STOCKTON, CA 95201388 Q Q6 d 7, 12091461-3420 NON•REPURDARLE PERMIT EXPIRES I YEAR FROM OATE13SUEO ICEmpIEIE In TPIPRBBIBI APPUCAININ IR HERE 1Y MADE TO THE BAN JOAOUIN COUNTY FOR A'"MIT TO CONITRLFCT AIIODR INSTALL THE WORK Of SCRIBED.TION APPLICATgN M MADE IN COMPL ANCE WITII BAN JOAOUIN COUNTY DEVELOP^/MNM TITLE.CHAPTER 9-1 16. AND T11E ATANDARLIN OF SAN.OAG11N COUNTY PUBLIC HE��A111LT///I I��NERNCES,ENVIRONMENTAL HEALTH OMSgFT. JOB ADORESSIOR AFNF ` ` 2 LVL[/ t— �4 J/41� FARM BIIE/ARN_ OLNNEII'RNAMF Della Garr as Agent ADDP�BR 242 Klo Road P4 ACNE COMRAt:ToR Clark Well, Inc. ADD,.RR2024 E Charter LK/ 371560R,oNEF 462-7676 RUN CONTRACTOR - ADDRESS UCE 1•IN1NF I TVP!OF WELURIBR: ❑NEW WELL REFIICFMFM WFIL 0 MONROA,NG WELL♦ ❑OTHER " y1� .❑-.�INNTAI!_ATPON ❑WELL AY.CT/[�M REPAIn ❑CMSS-CONNECT REPAIR ❑VAPOR E%TMCT.ON WELL/` SU J L3N—❑her, H.P. /may DNTH NMP 9ET FT. MEAT WATER LF+/FL p w, IRYR OF PUMPI Y-1�'T— !'-I f'l 1 v T Y (� l 13 OUTiN-BAEA•VI F WILL( j�1Elf0lj I1PC.AI WFIL I 0 NOIL NORINO M OFSTRl7CTgN: D I t VV USI � 1 D 1'C 1J�/ -- 'f — �A1� PFI-N��TEAETTFBOF WILL , CONS RilCTION RFECIgCATbRs A 1J S�lIBTR1AL ❑OPEN BOTTOM DIA. EXCAVATION f. OF WELL />Y A CIA.Of CONOt1CTOR CA8Nl0 O�-••�p�\- UJ'bOMFE TI'MMATE �RAVFL PACKMIZE- TYFE OF CARIN IT[EVPVC_ A VC DNA.OF WELL CASINO0. //�I D ! ❑PtIftIC fflAuwgo•AL ❑URVEN OEM.OF GROUT REAL T STECVICATDN 0 R�• ❑SBROATIOWAO ❑OTHER GROUT SEAL INITWED,T RBBY Lly I ORDW BRAND NAME W F'L E v ❑MONrT.RNO O[ .—ITT WAL.PUMPEOI'W YS. ❑NF CONCRETE PEDESTAL BY DRLLIM�LY« E)F.. S APNq X.DOTH LOCKING CHESTER RaX/STOVE P.VE S t#OPOSED CONSTTIUCTORMNNt U*G MET1gb: MUD ROTARY_ LI/ AIR ROTARY AMER �_CABLE DTHFR I NEMY CERTIFY THAT I IIAW PREPARED THIS APPLICATION AND 114AT THE WOPW MALL BE DONE W ACCORDANCE MATO SAN JOAOUBI COUNTY OIOINANCEI,►TATE LAWN,AND RULES AND MEOULETIONS OF THE BAN JOAOUIN COUNTY,HOMF OWNER ON IJC140ED AGENT'S SIONATURE CERTIRES THE FOLLOL'JNIG:'I CLRTH"Y THAT IN THE PETKORMANCE OF THE WOW FOR W HMH TIM P[RANi N ISSUED,1 SPALL NOT ELNMOY►ERBONS SUBJECT TO W04WAN'F COMP[NSATION LAWN IIF CALIFORNIA.' COMPACTOR'•HINNO OR SU6COWRACTNO 1RINATUE CERTIFIER THE FOLLTTWING; T CFRr FY AT 1 IE PEHT:OP,MANCE OF THE WOR:FDR WHIrH TH 1 PFRMA IS IMBUED,I SHALL EMPLOY PERSONS RUSJEC7 TO WORXFAAMB CGDE SATON UN F OF CALIFORNIA.• LM T E b N ADVANCE FON ALL FRO URF.IRRPE ONE AT 11BBI AY 11.COME COMPLETE GNAWING AT LOWER NA INLDIIS]Fl/ � 5*.,A J / TI11. Z. — T PIAN IO,w IA 14x.1 9v.1• 1. NAMES OF BTFill ORROADS NEAREST TO OR."'MR10 THE"PUTTY- 4. LOCATMI OF HOUSE BFWAOE CAPORAL BYBTFM On PAEHDRED !.OUTUNE Of THE PROPERTY.arvema DIAFENBONS AND NORTH GnECIPON. EAPANBDN OF SEWAGE DIWONAL RYSTEMB, ].GN.TFNBgNED OUTLTNFB AND LOCATION OF ALL EXNTIND AND IMOTDRTO B.LOCATION OF WELLN WITHIN RAOIUB OF ONE Hu—Ri FRY R, RTFNCTURES,INCLUDING COVERED MEAN SUCH AS PATIO@,DRIVEWAYS,AND WAU:S, ON THE PROPERTY ON ACIMPANO RgPERFI'. E. 1. 1. L ` user , �:. :.. I yl DEPARTMENT USE ONLY APPI4HIv1 A„•aetd BT D.t• A.r��/1 o B7�Y�'t'T1^— ACCOUNTING DRAY: AID/ FAC/ JI1 rt CODES FEE NFO AMOUNT RE1 1TiEO iFCX/ ABN RRCDVEO BT DATE /'EINMTRBRYICE RIOUEBT NUMBER INVOICE 40 Cc> Pub-H ant Sarv.-Enwo 173(a/96)