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1 <br /> APPLICATION FOR VVELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX, <br /> 304 19AST WI=Br:R AVENUE, STOCKrw CA 952014W <br /> (2091 409 3470 <br /> 1 <br /> MR-111f UJUABLI! PERMIT EXP[RE!J tA,R TAOM PATI ISSUED , <br /> S ,VII <br /> �f,�i (CaRlpitl•1B TrIp W161 <br /> AhE'{,ICAYIO1 IB HERE BY MADE TO INE QAN JOAOUIN COUNTY roq A PERMIT TO CONSTRUCT ANDIOp INSTAIL THE WOW bEBCIVRED 71119 APPLICATION IB MADE 1N COMI'1tA11CF WITH BAN <br /> 40AGUIN COUNTY DEVELOPMENT TITt ,C!\tj1 ER 4 1 116 3 AND IIE BTANDARD9 Of BAN JOAOUIN COUNTY PUBLIC HEALTH 9ERVICES,ENVIIItlNMENm HEALTH DIV19fON <br /> 0'a f,+tT'' JOB ADDMNNJVR PNI - L (r CITY hl PArICEL BIiEIAPNI_1�II,L. •r-L <br /> OWNER t NAME ti `-Il!N <br /> ADpREBB .., LI ' MIONE ECONTRALTOPHONE/ <br /> BUB CONTRACTOR f-1 ADOREQS UCI MIONE <br /> TYPE Qf WEUAVMI'z (A NEW WELL ❑ REPLACFME �yNT WELL IDI MONITORING WELL/±bW-1, 2# 3 © 0711tH_ <br /> ❑ INSTALLATION ❑WELL SYQTEM REPAIR ❑ CROBQ CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑Nwv❑Rwolf H P DEPT 11 PUMP BET FT fIR9T EL WATER LEVD <br /> f1YR`E OF PUMP, <br /> 13 E-1 f1�--�� <br /> OUT OF @ERVICE WELL LI OEOPI IV91CAL WELL I ❑ soli.BOILING B <br /> ❑DEBIRUCTION, <br /> P-� <br /> INTENDED E O Ctl PECIF C O r A <br /> 0 Et--TT INOUSTMAL 1J OPEN BOTTOMDIA OF WELL EXCAVATION `�.Z '.7 DIA OP CONOUCTOR CASINO_-_- _�_ O <br /> 11 /M <br /> OOMEBTICVVATE GRAVEL FACKIG?,,-� TYPE OF CAQINOI9TEEI/PVC__��J PIA Of WELL CASINO [,�r p <br /> ❑ PUBUCIMUNICIPAL ©DRIVEN DEPTH OF GROUT QEAI- 4 SPECIFICATION ft <br /> ❑ IRIVGAl1ON/AO ❑OTHER GROUT 9EAL INSTALLED BY L�\ GROW BRAND NAME f <br /> MONITORING ! OROUT 9EAL PUMPED, ®Y« ❑N. CONCMEE PEDESTAL BY DrULLER ❑Y. No S <br /> X DEfTII_ SCV_ LOCKING CHESTER BOX/STOVE f'1PE_W1�1 Rix IS+'� s <br /> tEb CONt1Tl10ilONIbI11WN Er11oO MVD ROTARY AIR ROTARY AUDER,_,�CABLE O1HE1{.____ <br /> Y ,� �i}Y CERTIFY TI(AT 1 NAVE FREPATIEp 71119 AI`I't1CAT10N ANp THAT THE WOIIC VJtIL Bt:BONE(N ACCORDANCE WITH BAH JOADVIN CbUNTY Or101NANCEB STATE LAW@ AND RULER AIM <br /> ItED11lATIGN9 Of TIfE SAN JOAOUEN COUNTY NOME OWNFR 6R LICENSED AOEN1 B SIGNATURE CEITTIfIE6 711E FOLLOVNNGI'1 CEIITIPY 7IIAi IN TTIE PERFORMANCE OF lift WOrw roR WIIfC11 <br /> j TIt19 PERMIT TS ISSUED 19NAU NOi EMTLOY T'ERQOHS SUBJECT TO WOhr(MAH Q COMPf]-ItAT108 LJ1WQ OF CAL1F011NM CONTRACTOR 6 HIyNO OII BUR�ONTRACTINO SIGNATURE CERT IFIEB <br /> Tiff FOLLOWIrIOs '! ERTIFY TI IN TIIE PERrflRMANCE OF TlIE WOfSL FOR Wr11CIL TIIIQ PERMIT 19 IBBVEO,1 91MLL EMPLOY PERSONS SUtI:JECT TO WORKMAN t COMPMRATION LAWS OF <br /> I CAUFORNlA TH C Hi CA HOUR IN ADVANCE FOR ALL REgU1REp INSFfCNON•AT I1oQI 466,2411 COMPLETE DRAWING AT LOWER AREA NIOVIDED <br /> 9lan.d x Tlu. <br /> Dq. <br /> PLOT PLAN(D,.w is 9".)9..1• to <br /> 1 NAMES O BTREET9 OR rtOAD9 NEAr1EBT TO OR BOUNb1NO TIfE PTTOPERTY 1 LOCATION OF HOUSE BEWAOE DISPOSAt BYBTEM DR Pnopo@fb <br /> I 01ITtINE OF THE PRIOPERTTY,GIVING DIMENSIONS AND NORTH DIRECTION EXPANSION OF QEWAGE OIQPOQAL SYQTEMS <br /> 3 DIMENBIDNED OVTUNF$AND LOCATION Of ALL EXISTING AND PROPOSED B LOCATION OF WELL9 WITITIN RADIUS OF ONE IIUNORED FIFTY f T <br /> 9TRUCTURE9,INCLUDING COVERED AREA@ SUCTT A9 PATIOS,DRWEWAYB AND WALKS ON THE T'ROPERTY OR ADJOINING FMPERTY <br /> I = I <br /> i s 3 i <br />