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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 386,304 EAST WEBER AVEWF_STOCK N,CA 95201368 <br /> (209)4583420 <br /> NOWNBUNCABLE PERMR EXPIR€s 1 YEAR FROM CATS 14$V f i�`�; 4 <br /> uw*%AS TrApr aW <br /> APPLICATION IS HERE SY MADE TO THE SAH JOAGUIN COUNTY FOR A PETV.IR TO CONSTRUCT AMIOR INSTALL THE VVRORL DESCPISEO.THIS APPLICATION IS MADE IN COMPLIANCE W TH SAN <br /> JOAOVIN COLWrY OEVS-OMAENT TITLE.CN ER 0-111&3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEFIVICES,ENVIRONMENTAL HEALTH DPATIION, <br /> JOB AOOWSSIOR/VIII *16CRY Tra(Lf PARCEL I RE/A~ <br /> ONSl71'S NAME 70 ADOESB <br /> °DINAR ADDREee <br /> .AOCONrRACTOFl L-Vli CI �Y �� Atom LjcI�� <br /> TYPE of wELIIRIMP: ❑ISM•WELL ❑REPLACEMENT VAU 13 MoNR oIwNO M/ET.L. ❑OTHER_ <br /> ❑MSTALUTION ❑WELL SYSTEM REPAIR ❑CR OSSCOHNECT PAP ❑VAPOR EXTIIACTION WEIL/'c_.._ J <br /> O ❑AAV M- N.P.��_ DEPTH PUMP$E7 FT. HRCT WATEn---L4 _ O <br /> Y� 0 OUTOFBERVICE WELL ❑OEOPHYGICAL WELL• ❑ SOIL FlORNG <br /> ❑DESTRUCTION: <br /> ON i ATO <br /> ❑INDUSTRIAL ❑OPEN BOTTOM M.OF WELL EXCAVATION D:A.OF CGNDVCTOA CASINO <br /> OOMESTIC)PRVATE ❑GRAVEL PACK/SM- TWE OF CASIMGMTEEINPVC OLA.OF WELL CASINO <br /> ❑PJKX Ml1FICPAL ❑DRIVEN DEPTH OF GROW REAL - SPECFICATNON R <br /> C3IRIIOATION/AG ❑OTHER GROUT BEAL INSTALLED SY GROUT BRAND NAME <br /> ❑MONITORING GROUT REAL PRIMPED:❑Vr ❑NA CONCI♦ETT:PEOEQTAL SY DRILLER❑YN ow— <br /> APPROX.DOTH LOCKING CHESTER SOXISTOVE PIPE_ <br /> PMPOSW CONSTN"CMKIONFLUNG ARSTHOO' MUO VOTARY^ ADI AIDTARY AUGER CASTE OTRNER <br /> I NFRMY CERTIFY THAT 1 HAVE PREPARED TMS APPLICATION AND IHAT THE WON(WILL BE DONE IN ACCORDANCE LMTH SAN JOAGUIN COUNTY OPOWAMMIL STATT LA' AND IBAE <br /> REGLILA IONS OF TIE SAN JOAOUIN COUNTY,HOME OWNER OR LICENSED AOEIR'S SIGNATURE CERRRES THE FOLLOWING;'1 CERTIFY THAT N THE PERFORMANCE OF THE WO1P EOR WN <br /> TMS PNORRT M ISSUED,I SHALL NOT EN PLOYPErAON1 SUSJECT TO WG%MAN'S COMPONSATION LAWS OF CAL%IQMNA,-CONTRACIOR•S HHOM OR PIS-CONTFACTNO BIGNATUIE C fi <br /> THE ROLL C[RTTFY THAT N TETE PERFORMANCE O►TNR'WON FOR VA%CN Tt���OMIPLFTIE <br /> ,f SHALL EMPLOY PERSONS PIRIECT TO WOI�HANY COSNOEt/{TpN lA <br /> CAUIN AOVANCB PoR ALL RlO11SRRS •�4p�/x�IS�.COMPLETE DRALMRq A71DNE71 AREA pEDNOED12, <br /> Slv�d XtT11._--_ { 6M.ROT MII m'_.fbi*NYA� I <br /> I.NAMES OF fTIQR ROS <br /> TS OADNEAREST TO OR SOUNpEIO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOKO <br /> 2.OUTLINE OF THE R10PERrY,GIVING DIMENSIONS AND NORTH ORECTION. EXPANODN OF SEWAGE bIGPOSAL SYSTEMS. <br /> i. 06WARRO ED OUTLAWS AND LOCATION OF ALL EXIPTMO ALIO PRIOPDSED S. LOCATION OF WELLS VM IN RADIUS OF OIL MIMPRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVETED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALLS, ON THE PROPERTY OR ADJONINU PROPERTY. <br /> f' <br /> z <br /> :............ <br /> PAYMENT <br /> REQEED <br /> fi • <br /> :........ ...:..,.:. w,Y... - <br /> :SAN JO, <br /> -PUBLIC <br /> €. <br /> DOANTMGNT WE ONLY <br /> ApoN iI.R ANAAFMd BY du _IVY Z <br /> G,.uU AM.0U M_ D.R. Atlmp RDIAAetlN,M _DFM / <br /> Ortrusller,IrrP.W—SY D.b <br /> ACCOUATINO ONLY: ADM FACS <br /> PA coca FES IPSO AAIO(ARRiSTTKD ,CASH ASCISVm SY GATE PHS,ST/SB1NCf REDUE1r INUAUS�1 INVOICE <br /> 05b a Or411w%' 73,;Z <br /> S IP, 9.952 <br />