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OAPPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAOUIII COUNT" PUBLIC HEALTH SERB <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 308. 446 N. SAN JOAnUIN ST., STOCKT681MIM , L HEALTH <br /> (209) 480-3420 PERMIT SERVICE <br /> rolt•RmusnAlty PEnw EKR"o 1 YFAR_mi DIRK UN 16 PH 4: 22 <br /> (C01*Iro in Tripwu) <br /> APPL=rON I8 HES BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE VYORK OESIC OF I.TWIG APPLICATION IS MADE Oil COlUO•LJMICE WITH BAN <br /> .IOAmm CommmVELOPMENTqq <br /> I,TrrM CHAPTER 8-1115.3/AND THE SrANDARDB/OF SAN JOAGUtN CCOOUNNTTY,PLJBW jKEAAL�TH sERVICM ENVIRONMENTAL WRAITH DIVIMCAL <br /> .IDH AD dOR AFW�+' sf Ls.��, j� r) �r CITY•�-� ! I�/7/ PARCEL GWAPW J <br /> aVWWN>3PB NA1rLE ]6�/ISG�'•�,,�`�f +�`I /�V 11 J y� A1N�sS FO / r'"� r'^ 1 PLfaNL r <br /> CONTRALTO �.. d�F1 LII✓oYJ• "�/l�Ll `'L AOOAEBB 7vB�li.t,��^ r, �� LIC/ _RLONE 1 [� f <br /> BUB CONTRACTO {,"----,r F-'�P�h-' 1 ADDRESS Imoq Id+�l� 6Wd� LIG rP�RL RIOM R -�T <br /> TYPE OF WE141PUM NEW WELL ❑ FakAcEum WELL 10 MOYSTOFOO WELL OMIV dD ❑ OTHF1k__ <br /> ❑ INSTALLAMN ❑WELL BIYSREM REPAIR ❑ CRDSB-0DNNECT REPAIR �ALI/ '• ❑ VAPOR PATWlrl N WELL I r <br /> 0 mm❑Rept H.P. DEPTH PUMP BET FT. F[RST WATER LLIIEL O <br /> [11fPE OF PUMP) <br /> ❑ OUT-c SERVICE WELL ❑ QXOMYSICAL WELL/ ❑ SOIL BOFM a <br /> ❑DEBTRLICTmN: <br /> PITENUM LWQP CONBTRIlCmm SA�TWAS ` 9/ A r� <br /> ❑ MnUSTRIAL ❑OPEN BOTTOM 01A.OF WELL EXCAVATION '19DIA.OPCONDUCfORCABOXR �J7M D <br /> ❑ DOMESrICAPOVATE ❑IRAVEL PAMMM I TYPE OF CABIN) AITEEVPVC D7A OF WELL CAMN 6 D Uj <br /> ❑ PUBUCAAIUNxvAL ❑DRIVEN DEPTH OF OROUT SEAL b BPEC[FVCATION R <br /> ❑ msm mmm ❑OTHER <br /> GROUT <br /> GROUT BPIAND NAME d5 <br /> MONITOI�IXR MIT - Y ❑No com: m PEDESTAL oy DRILLm❑Ys Oft <br /> APPtOIL OEPIN I BOXNMVL t9 <br /> PROPOBEb CO188Twimmmmmun ti 11WHOD: MUD,ROTARY Arg ff%v ftut AUGER _CABLP V <br /> Parmit MRV <br /> �V9 if W ;t <br /> 1 HEREBY CERTIFY THAT i HAVE PREP ACCORE MICE WITH BAN JOAQ=COUMN ORI7IlIMICEB.STATE LAWS.ANDMILES ANP <br /> REGULATmNB OF THE BAN JOAMIIN CERTIFIES THE FOLI.OAIYl M 9 CERTIFY THAT IN THE PERFORMANCE OF THE VHORRC FOR WHICH <br /> THIS PERMT 18 tSSM,I SHALL NOT TO I>t VVS OF CAUFrAWA.- CONTRACTOR-B HIMNO OR GI ONATURE CERTIFIER <br /> THE FOLLOW=; -I CERTIFY Y THAT IN IS ISSUED.I rAIALL EL,LPLOY I SUBJECT TO R WWAAWS CMWU"TWX LAWS OF <br /> O f] CALMRI"• APpLIOAMT ULIST O OI AOVANC6 FOR ALL h�O[Man AT POW COMPLETE DPMI M AT LOWER ARRA PROVIDED. <br /> sRmwd X title I-e �••- P" I' <br /> PWT FLAIL Mmv to Be"G= -to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDINB THE PROPERTY. 4. LOCATION OF HGIM BEWALLE DISPOSAL SYSTM OR PROPOSED <br /> 2. OUTLINE OF THE PROPO",01VIY6 DIYr�ONS AND NORTH DIRECTION. EXPANSION OF BEWARE DISPOSAL BYBTEIN <br /> 3. DWENSIONFD OUTLINES AND LOCATION OF ALL OUSTM AND PROPOSED G. LOCATION Of WE11S WITHMN RAO=OF ONE HUd1T0M FIFI Y FT. <br /> STRLICTMES,OKUM NO COVERED AREAS BLcH AS PAT=.DRNEWAYB,AND WALKS. ON THE PROPERTY OR ADJOUCW PROPERTY. <br /> lirao . �v <br /> S3cc- jN r f-q-, d- :I+ t <br /> . . ..-.. .... <br /> .. . .. .... <br /> ... ..... - - - .. ......................... .. - _.__-.. - --_ .. - <br /> .,.., ...... ... . - - ..:.. .. .. .. ..-. <br /> - .. ... .. - .. .. ... .......... .. ... .. '... <br /> DI�ARTII�IPT LIBX crD.r 41 *�APPAasrdm Aoc�d ILy Die <br /> &WA I.mpmam I3Y Daus PwrtPImP.g 1,i BT � <br /> canmemc �� � <br /> ASCOLr�IRo OILY: Alai FAG <br /> Ps roDES m ff" AMOUNT ROWITTED aHBCR! ABN RECEMID BY DATE powrlsorom8 Fulnum NIOilBER o1omm <br /> 4aa-0 00 <br />