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APPLICATION FOR MlETUPUMP PERMIT ORIGINAL <br /> SAN JOACIUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL IIEALTII DIVISION , <br /> 3(XEAST WERM AVEC S7nClCi�OM.C14 � <br /> 1209) 094M '.i—� <br /> no 9EE <br /> APPUCATNDN P HERE SY MAGE TO THE SAN JOAMM COUNTY FOR A PEANUT TO CoMrn=AM10lt MSTALL THE WOlK DEEgSEED.TILLS APPLlCAT10N ti tAl10E bi CONRLNCE WNTN SAN <br /> JOAOWV COUNTY pt1iB,DpftE}ET ,�CHIA �„t/116. AND THE 6T of�W,IpAp Cpy/ yl NNILSH f@IVICES.~R00 AWFAL HEALTH DIVISION, <br /> JOS ADONe�olt A,C71,/Su r .S 0 /( ,Z 90 � 51' . "[!.t/17"�C .ARCFL.QTJA,H, <br /> OM ERNS MANE G+Q AD'DRE/f�SL.--U�� �o�a PFIOFE,rip9 z39-y�7 r <br /> O" G 1 AOOIESS 3 7/ EN^ S <br /> .j. m. 11114 <br /> ADOIEM LIC+_ c 5� �w+oNE, <br /> T_rPE OF mfflu L O NEw WELL IVLACE1NBfT wELI M1 <br /> D NIQMrOIyNo WELL, ❑pT�, <br /> 0 INSTALLATION ❑ WELL SYSTEM REPAM 0 CMDOOCOECT IIEPPAM Q VAPOR EXfl1ACTION WELL <br /> RYP'E OF PUMP) , <br /> ❑Nwv❑IL�A�L' H.P. DEPTH P~SET . FR. F"w WATER LEVEL p <br /> D OtTTOFSERw=E WELD. D OLOPWMCAL WELL, , SdL oOISHO •: 1 <br /> ��tT1EA;lION: <br /> IfTENDW USE TVP!Of MRHJ. SPE�TION1 A <br /> D EXONFRIAL D OPEN sDTTOm OM.OF WELL lXCAVATION NMA.OF CONDUCTOR CASINO D . <br /> 13 OOMEammoVATE ❑SwAVEL PAcKmzE TYPE OF CAWNONTM PVC DUN.OF WELL K2A11ND p <br /> D PUKOCA UNKWAL Cl DWYER DEPTH OF GROW sEAI pip - A <br /> D NSOATKWAO ©OTHER OROUT SEAL OWALJIED K GROUT SRANO NAME E <br /> D wwromen .'7 , GRaLTr SEAL P Awap D Y« 13m, <br /> CONNCETE PEDESTAL K DlSLL.EItr Q Yr Qw t <br /> APP"Ux 067H 'L/7 LOCKING C*wAm DOXATTOVE PIPE S <br /> PROPOiED COIiKT11UC'FIOIIKDISLLJIID NNETHOO: MUD AOTARY AIR ROTARY AVOW CABLE OTHER <br /> li <br /> I HELY CEPMFY THAT 1 HAVE O EPAMM TMS,i4 XAIWN AND THAT THE V60W%LLL.SE DOBE M IAN J-=m COUNTY OR4IIA cm,RATE LAWi.AND IM)L8S AIS <br /> FMILATIONS OF THE SAM JOAOUM COtWFY. HONE OVO*R ORLXXNM II AaD"ORtNATU E C MPES TEE FCUOVA N6:T CERTIFY THAT W THE PEWOPO.IA"CE OF THE WORK FOR VAbC14 <br /> THIS P'EANOT P ISSUED,I SHALL HOT EMPLOY PERfSONe SUL)ECT TO MrORKMA"COMPAWAYM LAWS OF CALMOISLLA.- CONTRACTOR'S HOW40 OR SUS•CONTRACTINO SNONATUIE CERTSES <br /> THE POLLDW0A: •1 CERTIFY TNAT If THE PE <br /> RFORMANCER VAMC"THIS PEF"r 0 WVJED.I SHALL.EMPLOY PERSONS SU&R=TO WORKMAIM CO&lPSk&AT10N LAWS OF <br /> G11JP0lMJIA•' APPUCAHT / DOS)M)1PSC110N6 AT 0004Mit1l.COMPLETE OVAwn AT L0VAR ATEA P%OVwED. <br /> SmW tqr. -to - <br /> t. "NAMES OF STREETS OR ROADS NE.#AW TO OR SOUNDSNB T"E R'IRDPERTI'. 4. LOCATION OF V40M SEWAGE DISPOSAL Sl'STE A OR PIRDPOSED <br /> 2. OIRLKFE OFTHE PROPERTY.OMM DVAEM8XW9 AND NDRTTN UMECTKM DMANVOM OF SEWAGE DISPOSAL SYXTDn. <br /> 3. OMyENSIONED OtrrU NFA AND LOCA71ON OF ALL LVSTW.AND PROP'OM S. LOCATION OF VA:LLS WM*N RAMA OF ONE HUNDRED FWry FT.' <br /> STR ucnmtm RICLUotm COVETED ANEAS SL)C"Ai PATM.OR MEWAY8.AND WALKS, ON THE PROPOVY OR ADJOSbMO PRDPM Y. <br /> t. <br /> ; <br /> - <br /> ... ................ <br /> :...... MAP ON BACK ._ . <br /> ...... <br /> ...... ............ ...... <br /> ----------- --------- <br /> ............. ............. ..... ....... ................. ------------- <br /> O@AMSxJT U"ONLY <br /> APOSMtbn A�e�Pltl L+T <br /> litatt ka0ae41�n DF Duty P nw IDot. <br /> Dwtnetien' p -0 1 <br /> c4marAr": <br /> r✓Gc E �tJsl� y/D' _ <br /> ACCORhRIN4 ONLY; A. FAC, <br /> PE COOS{ rap" AMOL/FT rawA TTm CMECK,ICASH 195c"VFD SY DATE PDRONTNIERMCE FAMUEST NUMASPR W VOltf <br /> Z o /6q9 OlVfl <br />