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APPLICATION FOR VVELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICE <br /> k✓ ENVIRONMENTAL HEALTH DIVISION \..t <br /> P.O.BOX 388.314 EAST INE U-R A N E,S��N,CA 95201388 <br /> NONREFUNDABLE PERMIT EXPIRES-1 YEAR FAOM DATE ISSUED <br /> IGInpNu M ir40c{bI <br /> AMICAMN IS HERE BY MADE TO THE SAN"AWN COUNTY FOR A PERMIT 10 CONSTRUCT ANDOP INSTALL THE WORN TH Xn ED.THIS ApRNMENTA le MATE O COMPLIANCE WTtll SA <br /> CITY Framed/ _PARCEL eRElAA11-- <br /> JOAOUIN COUNTY TEVELOPMENT TOLE.CHAPTER 81115.3 y( AAN�D THE STANDARDS Of BAN JOAQUIN COUNTY RIBLW IIEALTN BEIIVICFS.ENVIppNMENTAL HEALTH pMSIO . <br /> JO,ADDTESeOR APNEyy� /--- JPHONE E� /Y <br /> ADfsRR <br /> OWNER'S NAME 90pIlONE1 <br /> I � AOfH1EBS�y�•...�TCjr.�'��"��Q�Q������ �� <br /> CONTRACTOR �'JI, //,�t+TKLIECI S.ai.Jxf pHGNE.//b7)�J/:iIJI <br /> NC ADDAFee lKLEf [iA^•�.`"�. <br /> me CONTRACTOR A <br /> ❑MONNORIHOWELLI ❑OTIIER��- J <br /> OF WEU UMP: ❑NEW WELL ❑REMCEMENT WELL [3VAlup EIRRACTIOH WELL{ <br /> O <br /> ❑ <br /> INSTALLATION ❑WELL SYSTEM REPAIR ❑CMRP�CONNECT REPAIR FIRST WATER LEVFt <br /> Ofl'T11 fB1Mp SET�R. R <br /> ❑Nµ❑R.ptlr N0. ❑ SoES SORDID <br /> RVPE Of NMpI [3OUT-0FRFPVICE WFIL 1 ❑OFOPIIVBO,AL WELL I <br /> DESTRUCTION:J�L A <br /> _ p{ipUCTIO_N{ECNICATION{ O <br /> INTENDED USE EYES Of WELL W.or•;�n•.w.�•- ---- <br /> ❑OMNWTToM OTA.Or V>EI L FXCAVAE PIN- p <br /> ❑INDUSTRIAL W.OF WELL CASINO <br /> TVTEOFCASINOISTE LKWC� R <br /> ❑TOMEOICRIOVATE ❑ORAVEI PACKISIZE 6pE U,fl,ION <br /> ❑RIRLICRAUww^L ❑DOVE" CF.PENOEOMVT SEAL Y E <br /> OPOui eRANO NAME-- <br /> ❑IRRIOATONIAO ❑OTHER OM,yMUI SEAL DIST Atnw PVA--� CONCRETE PEOERTALRVTWLLER:❑Y- ❑N° 5 <br /> GROTTY BEAT.r'UM1'FC'❑Yr ❑Ne S <br /> ❑MONITORING LOCKINR C"FATER SOKIRTOVE AR <br /> AEPPDX.OFIfN AVOFR CABLE OTHER <br /> AID I1[1T ARV <br /> IROEO{ED CONSTIIUCTIONAKSILUNO METHOD: MUD MTANV STATE M.ANT RALES ANO <br /> 1 HEREBY CEIITIFV THAT 1 HAVE MEPAREO THIS AFIIOATION AND THAT THE WORII WILL RE LONE tti ACCORDANCE MATH BAN JOAOVBI C01RrTY OIERNANCES. <br /> IIEODUTIO"S OF THE BAN JOAOVM COUNTY.NO OWNER OR LICENSED AGENT'.SIGNATURE CHHRIES THE FOLLOWING:-1 CERTIFY THAT M THE p(pORWANCE OF THENATU FGR WHICH <br /> THIS PERMIT IS OF <br /> S{TALL NOT COUNT PEROONP WSJ TO WORKMAN'{COMEETIIATION LAWS Of CALIFORNIA.-CONTRACTOR•s HIRING OR BUSLO"TRACTNIG SIONANiE CAWS OF <br /> EMMOY <br /> ALL <br /> THE FOLLO ": I Cry11CANT MAST CALL Z IEO^SI{M ADVIYFYYIFY THAT IN THEFAIICE THE fOI1 All.RFOUICYL Pf11TI"arKT10N{AT 12"14"HIS MnmD IS SIT3EESMCOMItETE p11AWING AT LOWER AREA pRID'VIDE EOI{ATION LAWS OF <br /> TRI. <br /> ep ed% Q <br /> ELOT MN RA.w le Setl.1 Se.le�•1°� <br /> {,LOCATION OF MUSE{EWAOE TRSPO{Al SYSTEM OR pppPOeED <br /> 1.NAMES OF STREETS On ROADS NEAREeT TO OP SOIROTNO THE ITOI'ERTV. EXPANSION OF SEWAGE OISFOSAL SYSTEMS. <br /> E.ONLINE OFTHE D pPEptY, <br /> OIVINU DIMENSIONS AND WITI N T`RQCHON. S.LOCATION OF WELLS WDERN RADIUS OF ONE HUNCREO FIFTY FT. <br /> J.OTMfNSIONED OVTLINre AND LOCATION OF ALL EXISTING ANO ptprOFEO ON THE P/IDPFRfY 011 ADJOINING rROPERfY. <br /> STRUCTURES.INCLUNNO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WAIKe. <br /> r,101 <br /> ISL <br /> I-,a .: <br /> //�� DrPMTMENT THE ONLY /.�•�/'L <br /> APPtl°°Ilen Ac-1 A O.le <br /> Dae IN-1 In.P.°ReR er <br /> Trem In.Pemmn <br /> By T.1. <br /> Te.P•cnen In.Pxsen Rv r / �7 <br /> DemIP.•1.: <br /> 6,C)S e/\(-ro eieh LRO/\ e LO L <br /> ACCOUMTINO ONLY, <br /> AIDE FACT <br /> EE CODESFEE IMO AMOUNT REMITTED Cll A' RECEIVED SY DAT� � i CE REOVFei NlIAN91 INVOICE <br />