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APPLICATION FOR WELLIPUNIP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES • <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PA,BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (2091468-3420 <br /> NOW'REFUNDABLE PERMIT EXPIRE? I YEAR FROM DATE ISSUED <br /> APRICATION IO HERE BY MADE TO THE BAN JOAAu5 ."OU IUMPYL'M TrgOe,EBI <br /> R A RPD TO CONSTRUCT ANEMIA INSTALL THE WO M DESCRIBED.THIS APPLICATION IR MADE IN COMMANCE WITH N <br /> JOAOUIN COUMV pFVELOFMEM TITLE.CHAPTER 9.1115.3 AND THE STANDARD CONSTRUCT <br /> OF BAN MADU A COUNTY PUBLIC HEALTH NAMES,ENVIRONMENTAL HEALTH W WN, <br /> JOB ADOpENRAN ANNE Cm��r�/�j� /) <br /> ,.F PARCEL BLLEIAPN <br /> DwNEn'R xAMF�r��p5 n F- tH c Anowso L3?,S' .JF G'-h 5/FciD 4q�G, 557-523A/ <br /> COW W70R <br /> r� .pDp.R <br /> 1 IEC <br /> t I—THOME, <br /> MATCOMMCTORIP/T rFJM M IL' AOMEBS /b L)MYF UCI ILZ GS AAM/ <br /> TVR OF WE 1 UMP OT MV/WELL ❑RFIACEMEM MIL ❑MONDORINO WEU.. AG-1 ❑OTHER <br /> ❑INSTALLATION 0 WELL SYSTEM REPAIR ❑CROPS CONNECT AFFAIR ❑VAPOR EXTRACTION WELL f J <br /> ❑N—O hN, N.P. DEPTH PUMP Bfi FT, <br /> RYR OF ATMA � flpBf WRITER 1EVFL Q <br /> ❑OOUUTAIF�P NAMEWELL <br /> ❑O OAIYSICAL WELL I ElRSDS BORNO <br /> )<DFBTISTION: ✓�TVT 'Q (,T>/I'1 s <br /> K <br /> IMTFHOfO USEYR OF WELL CON T —RATIO EPECIACATIONS <br /> ❑WOURTMAL ❑ORNBOTTOM <br /> OLA.OF WELL EXCAVATION RIA.OF CONDUCTOR CASINLI 9/ <br /> ❑OOMFSTICgWVATF 11 DRAWL PACK/BILE TYPE OF CASMO/STFEL/PVC OLA.OF WIDE.CASING <br /> 11VN <br /> AIRLIbMICIFAL ❑DRIVEN O <br /> OfITll OF GROW MAL SPECIFICATION- <br /> 11 <br /> RCIfN.'ATION A <br /> ❑MARATIONIAO L3DTMq OIb1AREAL INSTALLER BY OMM C BRAND NAME <br /> ❑MONAOMNO E <br /> DWM SEAL A/RAPECMPI0 Y- [IN. CONCRETE PEMRfAL BV gVLLfA:L�Yr QNe S <br /> APPROX.OEPTN Np CMUbf[R LOCKING BOXAIOVE RR <br /> A101bf1O COMfA1UCA /gWNUMB:ONENO Mp; MW RpTARV AM IOTApy AUpfq CABLE OTMq R <br /> I ;ZI CFMIFV--I1-11 PRFPARD THIS APAICAI*-AND THAT THE WORK WILL BF GONE M ACCO I'OANCF WIIN RAN JOAWIN COUNTY ORDINANCES.TATE IAW4 AND RULES AND <br /> pFOUTATIONS Of THE SAN MAGUM COUNTY. HOME OVMfq OR LICENSED AGENT'S MONATURF CERTAIN THE FOLLOWING:•I CfTI[V THAT M THF PERFORMANCE OF TILE NN)RL fOp WNICry <br /> TRB BUEO,IMALI"TEMROYKRWNSSMIKTTOWOBSMAN-SCOMF SAAONIAWROf CAL"MA.•COMRACTORSITYFb OR <br /> RUBLOMMCTINO RIONATUR CERTMES <br /> TNF LLOIMNp: 1 GENTLEV THAT M THE RRFOpA1ANCE Of THE WORL FOp VMICII THIS RgMli IS ISSUER,1 PIIAIt EMPLOY RpWNP BURIfCi TO IND FOR COMFdSAibM LAWS OF <br /> GRILLE IA.' T APNCAM VRT ALL]I N ADVANCE FOR ALL pfUUMEO IMIPECIbNR AT ItMI1SRNFS. COO MR <br /> dUW1ND AT LOWER AREA ZIMIPM <br /> OIMnf X nP. /�,O✓//n ,. Dn. �o- 9-9(y <br /> ROT[UN RX_IS Se.I.I MPe e _ <br /> L NAMES OF TRFTB Oq WAOB E ST TOOp BOUNCING THE TDRnry. 1 LOCATION OF HOUSE SEWAGE gRFOSAL RYTFM OpIMIq BEO <br /> L OUTLINE OF TILE PROPENTY,O OIMENOMNB AND NORTH DIRECTION, f%PANNZH Of SEWAGE dMVUL SYSTEM, <br /> ]. DIMENBONEO OUTLINER AND OCATION Of ALL EXITING Am PROMISED R,LOCATION OF WFLLR WRHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURESS.INCLUDING COVERED AREAS SUCH AS PATIOS,DMVEWAVK AND WALKS. ON THE RORgry OR ApJOININO RORgTy, <br /> l 5EE 4Tr4e,14MCNT <br /> ..... <br /> p OEPMTMMT WR ONLY <br /> AFPWMw.Aeeeplee Br ,I( t-../y�P..gp�-L�(,��0 A,..�__ <br /> D.oUI lmpmOen By 1J D.0 RmP Ii+emVan By <br /> Dm <br /> Dr111n11en Imerlwn By �. ! / <br /> P <br /> ACCOUxiwO ONLY: Apt FACE <br /> 4COO. FR INFO AMOUNT SMART V CHICAITCAIH BFCDVEG BY 'OTE PAWNTIMEMCE RFOOER I REA N DICE <br />