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r:4 c LT . <br />• 4, t • <br />DEC: --419% <br />, <br />f: <br />1.1,08/(P, <br />0:S <br /> CNN <br />(),NL,I.,-1,-L—X-1-0.-, CNA <br />)4e; <br />DEPAPITMENT USE ONLY <br />APvileeilen Ave.ga.A My <br />019. IrweeA,I.N. By CAN• <br />Ldt 11 <br />6 <br />0 <br />'7 <br />TLE., InteentleA, Sy <br />Pr <br />C•Immr.1, <br />Dm. <br />06V -57 .LY <br />APPLICATION FOR WELL,PUMP PERMIT <br />SAN JOAIMIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE. STOCKTON, CA 95201-388 <br />12091 45113420 <br />PION.REFIINDARLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />ice.p1.14 h. Tr105F1111 APT', !CATION In NEVE NY MADE TO THE PAN JOAOUIN COUNTY TOR A 1E01E1 coNx10001 000100 INsTML THE WORE DESCRIBED THIS APPLJCATION IS MADE Al COMMIANCE VITT!, 5.1. JOAQUIN COUNTY DEVELOPMENT TOLE. CHAPTER 9-1115.3 AND [14( FE ANDARon OF RAN JOAQUIN COUNTY PUBLIC NF/,L/II SERVICES ENVIRONMENTAL HEALTH DIVINCN. <br />JOB ADDRESS/0F MINE , s- <br />ct Tr 3 l'yz 42.5 ;74 PARCEL SITEJAPNO_ <br />...CRS NAME C Z-4 1V P P,(Lycjia..._ Iç ADDREEF s, , Y3/ -3 /."5- enNillACT041 /-7s -t - ADDRESS <br />NOS 5 <br />1 6/,„0-4„,:,,ovf 631-'3 ..5-1410NF / - y//4 <br />CONTRACTOR AOTHIESS UCE PHONE <br />TYPE oF wELLypI7Mr: 0 NEW WELL <br />171 INSTALLATION <br />0 N.J. <br />DOW or PUNE, <br />Eli DENT/N.4c NON: <br />0 MIX AcFMENT WELL <br />0 WELL Br EM REPAIR <br />HP, <br />0 OUT or SERVICE wE41 <br />0 mown Down vital. s o OTNER <br />CAO99.CONTLFCT REPAIR <br /> <br />0 VAPOR EXTRACTION WILL <br />010111 0)111 BET 9.-3 0 VT. FIRST WATER LEVEl__24 <br />0 OFOLEIYFICAI writ V 0 POE. .01E40 <br />01E0010 UPI TYPE OF WELL CONSTRUCTION ApICITICA11011111 A 0 TM 1511501. 111 OPEN NOTTOM DIA OF WELL EXCAvAlfoN DIA. or CONDUCTOR CASPEO p ^4D <br />0 0 ocmiSTIC4PRIVATE 0 GRAVEL PACK/947E TYPE OF CAsmn/F tEl 1 rt-vC MA. OF WELL CASINO 0 ......... <br />0 PORI ICANNOCIPAL 0 OfavEN nomi of OfInuT TEAL sPECIFICAfioN 0 IRMILA I ION/AO 0 orfrEn (MOM 6,41 *MT MIFF) RV OWILIr SRAM NAME F (r\ ID MONITORNa 05001 ETA! PuMPFI) 0v114 0 N. cONCRETE PEDESTAL BY DRILLER 0y.. 0.. <br />APPPDX, DEPTH 1,000100 CHEATED DOX/9100E PIPE <br />PROPOSED CONSTRUCTOWDECRUPIO METHOD: MO ROTARY AIR 1101A0Y AVOER CABLE 0TI4E11 <br />1 HERESY CERTIFY 714AT I 14AVE PREPAREO THIS AIRPUCATION ANC/ 111.50 THE Wolic 'ML AF DONE IN ACCORDANCE wfk SAN JOAOUIN COUNTY oFIRNANCES. MATE LAWS. AND RUIF AND TUTFA ATIONs oF Till SAN JOAOUTN coopfry. HOME OWNER OR 1,11(01100 ACIENTS NONATIME CERTIFIES TM FOLIC...No: .! CERTIFY 111A1 /Al THE PERFORANINCE OF ENE WORK FOR WISC. TIRO PIREAIT 111 ISSUED. 1 WALL 140E0.101.0Y PISTON, SUBJECT TO SMARM!. I coOPENII ATM N 1AWS OF CATIFORNIA.• COMPAC TOR'S MEMO 011114/11.CONTRACTINO SIGNATURE CR7714146 V) <br />THE ToLLOWIMS I CERTIFY THAT IN THE PERTORMANCI Of 1HE WORK Ion TM-OCT 11115 PEPMFT M !SMALL I SHALL EMPLOY PENNONS SUBJECT 70 WORKMAN'S comma...non TAWS OE CALIFORNIA. THE CANT MUST CALL 213J IN ADVANCE FOR All AIroURIVO IAMPECTONS AT IERSI AREJ432. COMPLETE DILAVONO AT LOWER AREA PROVIDED. <br />11Ened <br />PIVOT PLAN 01./A0 1 141(01 Sy•lx <br />I. NAVES OF sTREETS OR IMAM/ NEAREST TO OR BOUNDENO THE FOOTIRTY. <br />3. MOTs* Of THE SOOPENTy. cnVINO DIMENSIONS AND N011014 Offiscism. <br />0. ORSENSR,NEn nUTUNfl ANC, LocATNNI Of Alt Marlivo AND PRoPosTO <br />etRlIc TOMB INcLURNNO COVET/AD AREAS SUCH AR PATIOS. INavEV.AYG. AND WALLS <br /> <br />I. LOCATION Of NOUSE MEWAGE 015100A0 AYITTEN nn Pnorosto <br />Expansion OF IltINAOE DISPOIAL SYSTEMS. <br />S. LOCATION Of WELLS WITHIN MENUS 01 0110 NUNDAEO FIFTY FT. <br />ON THE PROPEPTY on ADJOINING INKIPENTY. <br />AcCOUNIINCI oNLY ADIS -{ ,c• <br />PE COOEC TEE ago AMOUNT 5115111110 CINCI1 CAIN ALCOVED VT OATS PlIGAITNEALICE IREENN1T MAIM <br />— <br />INVOICE <br />113Z° OSP S C) 4"0-C2 41 1 LB 1?-1419 .....S)ic.60 //6/3 0 1}-1, --(1- <br />_ ______ J <br />Tiv.. 1.4.1.141/-4' <br />Pub. Health Serv. - Enviro. 173 (3/96)