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APPLICATION FOR WELLIPUMP PERMIT )Pe, YO4f- ^�. SAN JDAOUIN COUNTY PUBLIC HEALTH SERVICES �"SBSS-�Co ENVIRONMENTAL HEALTH DIVISION • P•0,BOX 300,304 EAST WEBER AVENUE,STOCKTON,CA�201308 12091488-3420 ON N ABLE PERMIT EXPIRES I YEAR FROM GATE ISSUES JLJ K API'LICATbpE N I81RBY MADE TO THE RAN LbAOVIN COUNTY FOR A R ICamPMb M TriPRe[Iq IIT TO CONSTRUCT ANDMA INSTALL THE WOR(DESCRIBED.THIS AMMAT1ON IS MADE 1N COMMANCE"M SAN "AMIN COUNTY OEVELOMEW TRUE,CHAPTER 9-I I I N.3 AIA THE BTANOAMR OF BAN MAMIN COUNTY FURUC HEALTH SERVICES,FNNIM)NMFMAL HEALTH OMMN. JOB ADMSMR Af[,N(I/�_ A Q'I CITY.. Z,4 A v A PAIICK M211A 1 _ OWNER'S NAME /I- I�W LJ�IPS O Stk�/LA.- ADDRESS 1JZS• jS4-. AECPHONE 3 CONTRACTOR T AIXMEBR LbF P1bNE1 SUB CONTRACTOR Snr.L{-rww. t=,c p(nr .-- lL. ADDRESS(i.Jl(J WI�41 n�_w M, ZZ(,9 RHONFF 10✓-O llv TYiE OF WELL/RIMP ❑NflY WELL ❑mw NACEMF WELL Ll MONRORMO WELL I i-3 ❑OTHER ❑mBTALLATION ❑WELL SYSTEM SEPAM ❑CROSS CONNECT REPAIR ❑WkEOR EXTMC MM WELL I J Fm OF RIM% ❑Nwv❑R.pNr M.P. DEPTH FVMP SFT_FT, FIRST WATER LEVEL O y UT -OFWELL ❑'GEOPHY�SICWELL 1-- �. O LJ Rot BORNO ✓✓ 'DErtRNCTDN: /"WIC ❑n5/11s ^J ftl ly"SIRISILL t—CONSTRUCTION FCIFIc TION A ❑INOUSIRIAI 0014N BOTTOMVA.OF WELL FXCAVATMN DIA.OF CONDUCTORCA.SIINNG ❑OUNIMIC/%tlVATF 11 BRAWL PACXIM2f TYPE OF CABINDUSTEEIIPVC VA.OF WELL CAMNO ❑FURUCMUNICIPAL ❑OPNEN M"OF MOOT,FAL SPECIRbATbN R ❑IRMOATbNIAO O THF. OWST GROUT INSTALLED MIT ED BY ORRAND NAME F ❑ MONITORING GNOUTSFALFVMMO:ElYm [IN. CONCRETERNWRTALOYDNLLEn:0Yw [IN. S APPROX.DEPTH LOCXIM CHESTER ROX/SHOVE FRE I MODSM CONSTRUCTONMRUNO METHOD: MUD NOTARY Ain MTMY AUGER CABLE OTHER I I%%RY CERTRY THAT I HAW MErAREO THUS AM'UCATX N AND THAT THE WORN WILL BE NONE W ACCORDANCE Wit"SAN"AMIN COUNTY ONOINAMFS.SPATE LAWS,ANO RULE.AND NEOULATMNB OF THE BAN MATRON COUNTY. MME OWNEn OR LICENSED AGENT'S MONATURE CEIRRIEB THE FOLLOWING 'I CES TRY THAT M THE PFNOm.IANCE OF THE MW MA"ileN THISFERMR IB MSUEO,HSHALLMTEMMOYMMONBWSACTTOWOn AN'SCOMfMBATONLAWSOFCALWOM1A.•COWMCTORSHIRINGORSU"OMMCTMBMHATUMCEMIF1ES THE FOLLOMM: •1 CERTIFY THAT m THE PERFORMANCE OF THE WOM FOR WHICH TNI,FEPMR IB ROUND,I SHALL EMKOY IERbNe RUWcT TO WOnS AAN'B CORKNsATON LAWS OF CAUFOPMA• TM1yAPyFNCAMT EIIMT CALL N 1bU1B IpN AOVAN E POIp�AIyI-LUMLOUBtp IMBPiCIroNB At IEOBI Nq.NOB.CONFUTE DRAWING AT LOWER AMA R1pWOFp, On. %Or RAN ON—Ie GW.)Betl. •Ie 1. NAME$OF STRETD OR MADS NEAREST TO OR NOUNOINO THE FRO ERTY. I. LOCATION OF MUSE SEWAGE GIMBAL SYSTEM OR M[IMSfO 2.OUTLINE OF TIIE MbPFR ,OIWNO OUSHRONS ANO MRIH DIRECTION. FXPANMON OF IMAGE GMOSAL SYSTEM,. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND NroMSFO R. LOCATION OF WFLL9 WIINM MDIU$OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATHOS,INGYMAYB,AM WAUne. ON THE FMFEpry OR ADJOINING FROIEnny. M.rfWnv M •N+" w+w ti.R PmINM BS.nIInSIq$AM QI:wR��.'R'i.niwr T [��tmnw S.11llFr. nYlFFaa �•• i.I.M4,rR FPnI- i ps SFA_ R 3tr L�-.+�.. A�1:SU9 MFIM _ oY.I.F....\ - Cl TT+rwry 0..,wwW�ml OR.wpwe. , 0....M a1 R ,�. OHO... . m........_�. �_ C I ❑.n.��el O ___._ Om.,.r , O l.nnp VRrSHM YM�I,rRM.M � G BF1pRpwRwIT �. �ITIRATARR G MIT.NAIt Q,RrM�� aF.mMrR.R .w\e..I..I7 /L•• ❑13 nr.• �e.y '�NSBr.K BMS,M� wBa�r,m� �rRIIBM a!•IFY+ I ....R.L�O..0. FMMMB.Nm..O•.O+ ww.... ..e F.qF..w.I.w MYIY�eq�IIv.�.+r+Jwr...e.n M,r R.:. '^`••••,(w.w=IAM;r� IIiTEF�IO w•I�F wa\1T,MM.r4HM,I.srww.r. n �MIa•A.ITMw,.sr - MO'N , T-� PrmPRM mIRM1IMIYFI rur,u Rn.�v�� _v .RRyNRNR MrM.* 'S'"" BR .NINR.Tp.u1�wYA.FIpFM�wIRF/My mF...R.IMIIF�\VIY wwR. E Imaw�.vr:Y.mlwrl„Ymm�jlB.enY11�.n, •ErIpFIMB.rY�MTi RR1IIRMA, R..RTMRR MiTM6 wI11rPnRrIWIMr. ... .. r�OFPARTMFNT USE ONLY APVIIa.Im Avemltl SY /1 L/W OH. t0 3a A,m 7 (o- OreN IrnpmGen SY Br ��y,�M� � Pump ImpmHlen BY / Dy^M. omincnen Inomlbn \_W V YgN✓'Cib ON. Demmml.• -� 0 AC....TV.ONLY: NOI FAC. PE CODES FEF INFO RISIUNT PURIM CWCXIFASH nECEIVEG SY GATE REMITISM"CE REQUEST NIX.1R91 INVOICE M--i LE 0 L5L to Io <