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T — - / <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOACUIN C9UNTT PIIBLIIilE:'ALtH BEOVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 988,304 EAST VVEBM AVF-NUE.STOOMR CA 9b I_W <br /> (208)488.3420 <br /> NON-REFUNDABLE PERMfT EllPIRF! 1 YEAR FROM DA7E MUM <br /> (GBgYM In TrlpRellb) <br /> APPLICATION on HERE B1'MADE TO r W BAN JOAMN COUNTY FOR A PFRLNT TO COHeTRUCT AND/OR INSTALL THE WORK OESCRSED.THIS APPLICATION NI MADE IN COMPLIANCE MM@M <br /> "ADM COIIMY DrAWPMENT TITLE,CHAPTER 9-1115.3 AND THE QTANDARDB OF BAN JOAOUIN COUNTY PU/IK <br /> IHEALTH 0XVICEB,ENVIRONMENTAL HEALTH OrVwO%. <br /> OIIE <br /> JOB ADSSAR APN/ CITY A!//I/�Y� PARCEL EIZE/APNf <br /> OWNEII'B NAME / <br /> AOO11EdS r PRONE <br /> CONr14lCTIM ADDIESE. c !/ ��//��1J�uct <br /> SUS CONTRACTOR ADDRE. //o �� l1Cdf <br /> TYFE of NEV-MUMP•V{1Y WELL ❑REPLACEMENT WELL ❑MOMTORMO WELL I ❑OTHER <br /> ❑INSTALLATION ClWELL SYBTEM REPAIR 11CROGS-COHNFCT REPAIR ElVAPOR EXTRACTION WELL P J <br /> /LwNw❑PAPw H.P._ DEPTH PIMP BET FT. FEW WATER LIVET 0 <br /> A OF PRIAPI -- <br /> ❑OUT-OFSERVICE WELL ❑SEOIR YMAL WELL P ❑ am so RIM d <br /> ❑DEETRUCTIOM <br /> iLL CON N d O A <br /> i �A❑ IRO �11MUMAL ❑o orm ROrTOM DIA.OF WELL EXCAVATION Df&OF CONOLICTOR CAMM p <br /> ,M )w-MRdTICVATf 1,15z <br /> -M PACKIMZE TYPE OF CASINOATEEUPVC_ G OTA.OF WELL CAANO �E <br /> • ❑PAHICMIMCIPAL ❑DRIVEN <br /> V[N DEPTH OF GROUT SEAL SPECIFICATION C L <br /> A <br /> IIVSOAiION/Ao ❑OTHFq GROUT REAL INSTALLED SY 01g1R BRANDNAME ! <br /> ❑MOMrONNO r OROUT SFA[PVMPEDWYr ❑N. CONCRETE PFOFSTAl BY DNLlEN❑Y. d. <br /> APPROX.DEPTH LOCKINO CHESTER DDK/STOVE RPE <br /> d <br /> PROPOSm COIISTNUCr10RlEIBILNO METIIoo: MNID ROTARY AIR PIOTARY AUGER CABLE OTHER <br /> I HMNY CERTIFY THAT I HAVE PREPARED TT.$AP LICATION AND THAT THE WOW WILL PE DONE IN ACCORDANCE WITH BAN JOADIAN COUNTY OFIDWANCBB.BrATF LAWB.AND RULES AND <br /> REOU AT10HS OF THE SAN JOAOUM COUNTY./TOME OWNER OR LICENSED AGENT'S MNATURIF W <br /> CEITTKES iNE FOLLOWING:'1 CERTIFY THAI R TN[PEIEOIS.IANCE OF THE WOKS(I'011 IIICN <br /> THIS R1SAR b IBSII[D,1 SHALL NOT FMPOY PERSONS SUBJECT TO WOIIRMMM COMPINIIATWN LAWS Of CALIrORN1A.•CONTRACTOR's mmM OR"B CoNTRACTMD 910MATM CERTRES <br /> THE FOLLOWIIq: • TH M THE PERFORMANCE OF THE WOPK FOR WHK'H TSS PEAMT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO NOMQMAWS CompESSAIR"LAWS Of <br /> CALIF011NI11' T C N ADVANCES FOR ALL RSOISRM jK"ECTI R"T 170411I AM�SM /, COMPLETE DMWM1NO AT LOWETI ATEA RIROO/lro <br /> POT PUN IDI-1.0".l SP.1. •1. <br /> 1.NAMES OF STREETS OR ROAOB NEARER TO OR POlN40NM TNF PROPERTY. 4. LOCAYON OF HOUSE BEWAOE DISPDSAt SY/EEM OR RVTIOQb <br /> 2.OVTUMl OF THE PROPERTY,GRIM DIMENSIONS AND NORTH DRECTION. EXPANWN OF SEWAGE DISPOSAL SYTrEME. <br /> 7.OSAENAOWD OVrLd1F.6 AND LOCAT"OF ALL EX ITRO AND r mpD S.LOCATION OF WEWTrI1NM RADIUS OF ON[MAIOIEb fl►TY FT. <br /> QTIRIC — <br /> t <br /> -�»t*4 <br /> r- <br /> Nrr 'S..wLt <br /> ,.r......; <br /> AUG -11996 <br /> rT. <br /> SAN JO IN ZN�—" <br /> PUBLIC H LTF SERVICES 1 Tv-Fr " M�arwTFAw <br /> VIRONMEN LHE ALTH DIVISION :d ... �,..... <br /> sy 1 <br /> f/•IS...A..F <br /> APPR..LI ■"tl Rw)rtl-LSIRTr �1 <br /> .P.CIIG.8T <br /> DN. <br /> D. - 'Z!` <br /> cemm..,n: ��,•Fr <br /> ACCOlR1T1NO ONLY: ATO. FACS F <br /> PC CODES FEE INFO AMOUNT NDAITTFD CHECBI/C AIN RECOVRD SY DATE P~TlSRIVICB REQUEST NLAIN91 .� INVOIC■ <br /> 3 ( G <br /> v7., <br />