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APPLICATION FOR WELLIPUMP PERMIT <br /> i SAN JDAOIIIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIROMMENTAL HEALTH DIVISION 2.D2— <br /> 334 EAST WEBER AVENUE-4 STOCKTOK CA <br /> 92EM 458.3= <br /> A.y <br /> ttONAMMetf PFaNrrr <br /> APPLICATION Ili HM BY MADE TD THE 9"JOAOUIN CDt*Tr Y FOR A PEPW To CONSTRUCT AND OR WGTALL THE WOIK OESCRIBED.THK APPLICATION tS MADE IN COMFIJ.WCi wrrm SAN <br /> 1 JDAODU+COUNTY DEVE MPME Nr TM.L CHAPTER SA 115-3 AND THE LTANDAMS OF IAN JOAOM COUNTY PUBLIC NFALTH WW=.L3flAIlONME3rTAL HEALTH DIVAmm. <br /> ? P <br /> .TOE ADLIIIE86IOR APH. J 1 Gt C l L- C"Y <br /> j OWNER'f MAlu1f i aSL.� '�' t4+(YCtk �'b c Am11Ess J QLc A I Z-:> P}IDNE, k:,--k)72 -Z /c <br /> c�— <br /> eoirrn D�IG� uy�t 6%-!n:54 <br /> �C ADaNEsclo`7'yTSE�rtr�C'f Sr�[tc.1 u= P"ouEW§o . =1SSS <br /> sus coerElu^TOR Qwc C�c %- y 1 �7 14 <br /> AL701�6P,o,B�sJC3�.Plp 1Si�..1�IC SZ.I./0�llPHOHE 07 7,Y-T3txfJ <br /> TYPE OF wEulP.Uult~ ❑ HEW WML fl FV"ZEUE rr WELL ❑ wown:,mm vmL r D ant <br /> ❑ WMTAL LATIOW ❑ WELL SYSTEM MY-AM © CPOW-(X*0 CT WART ❑ VAPOR ECTR lLTION WELL r . . J . <br /> 0 N.r.D R...h TIP_ DEPTH PUIIAIPS4T FT. FrIBT WATER LEV4 G ' <br /> rTYPE OF PU W <br /> fl OW4W-mrules W U /} i.7 SAL WELL r D Bort sopow B <br />$ OEBTRIXTIOW, }'✓�1J ^Z{ >7J(i �C7�t l 6�I[�C C'r�iG' rGv//E�r17 C f'✓lcc,tj_. r' p r. S <br /> INTTdIOFD USE TYPE OF WELL CONSTRUCTION S►EC.gCATIDM rr - A f <br /> fl NOUS MA0 ❑OPEN"OTTOM W.OF WELL EXCRVAT)DN � WL OF CONVECTOR CAMNG A <br /> D <br /> DOMESTIC/P OVATE C3OMVEL PA=M= TTPE OF CJRWNXIIGnm,,-,. L TVA.OF WELL CASING D <br /> D P ISLICI rt1MCIPAL D DRIVEN bs rH OF OIIOUT SEAL _ WTOFICATTON R <br />{ ❑ IAig04T10WAG G OTHER GROUT SEAL INSTALLED By OMUT SRAM NAME <br /> MONITORING WC UT SEAL PUMPED: 13 Ya ON.. CONCRETE PmEDECTAL BY murk❑Ye. ❑Ne S <br /> ff IIAPPNOIL OWrW LACKM CHESTTH SOXWTOVE S <br /> �•"OPOSED CO NlTRUCTTONIDRSL XQ FALTHOD. MLM IgTARY AIR ROTARY AUOF74 LABLE OTHER <br /> f <br /> I HE4@SY CERTIFY THAT I HAVE PREPARED T}OS APPLJCATIDN AND THAT THE WORK WALL BE DONE IN ACCORlW=WTH SAN JOA=M COUNTY ORDINANCES.STATE LAWS.ANO RULES AND <br /> REOULATIONS OF THE GRN JOAMM CDUNTY. HOME OWNER OR L)CEWVM AGENT'S WONATUI#E CERTIgEt THE POLLOWM:'I CERTIFY THAT W THE PERFOFOAANCE OFTHE WORK FOR WHICH <br /> y TM PERMIT IS tBWM.1 SHALL NOT EMPLOY PERSONS SUBIEL'T TO WOPOCUAPM COMMOMATWIt LAWS CW CJIL7FO1M&- CON'TRACTOIYS HWSM OR Bt1bCONTR4'T1N0 SIGNATURE CERTTFIES � <br /> THE FOUDWINR: -I C9ffIFYTKf.T IN THE PERFORMANCE OF THE WOW IDR WH=THIS P99 T IS ISRUEt),1 SHALL EMRANS Y PERSOSUL=7 TV WORMAlt S COMPOMATTON LAWS OF <br /> CALJFORNLI' ZA FID IM ASA/ANCE POR ALL 11i4t1RFA Ni AT L2OS}dam-lm=. COMR.ET-E DRAWING A7 LDLVER AREA PIbV[ , <br /> I s+v.rd z r <br /> 3 <br />[ 1. NAMES OF VTI¢ETS OR RDADS NEAIIESS TO OR BOUPWfM THE MCPERM - A. LOCATION OF HOUSE SEWAGE OtSPOSAL rnrrEM OR pmo.poSED <br /> 2. 01trUNE OF THE PIIOP K Y.DIVING DIMENSIONS AND NORTH DIRECTICK _ EXPANSION OF SEWAGE 018MBAL SYSTEMS. <br /> 1. DIMENSIONED OUTLINES AND LOCATION OF ALL EXt9rING AND POOPOSED L_ LDCATION OFWEILS WTHIN mores OF ONE HUNORm FIFTY F$. <br /> STRU--TUFn.pi=X*NG COVETED AREAS SUCH AS PATIOS.DRIVEWAYL.AND WALM ON THE PF0PEKrY OR ADJOINING PROPERTY. <br /> -F i <br /> :_ f3 1998 ... .... ; .. :. . <br /> ......... - nlr: MAP ON BACK .. f <br /> :a: <br /> A <br /> . <br /> .....-:.... E <br /> EVletOf7Ni�eV.,Fy icALTh uIVISION <br /> II DB'AKTMBU LISE'CXLT <br /> A..1A..ew..Ae-rptrd�' D-A. Ati <br /> `i <br /> or.Iu i+roostkx 91' Dot Pump wwu-coon tvf LMs. 13 <br /> n,n.,.r Al mi ( — `f <br /> _,. . .l ----- - <br /> I IA=O UKT a ONtr: A=W FAC/ <br /> PE COZIES <br /> I }g LAPD AMOIAr.-RB-BTTM C AIH W=WVM WY DATE ""NTISERNWE"MUERT NMA TIER INVOICE <br /> 3S. V2-1,571 r Of 5 79 <br />