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APPLIE IN FOR WELLIPUMP PERMIT DDy�3y SAN JOAOU:R,IUNTY PUBLIC HEALTH SERVICES v ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201588 (2091459-3420 NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED 0ROPYM In T,iPiWMI _ CONTUOND TO CDNlNJCT ANDMIl ETAL ASCRIBED pgIM COU1NTY DEWORMENT TITLE.CHAPTER 9.1115.3 AND THE ST/A]NDAARESDEAN)DAOVIM CITHE EA PERE 91 MADE TO THE SAN"AGUIN COUNTY FOR AOUNFY MOM HEALTH SEPVICEB.HENMRONMENTAL HEALTH DRAWN MB AOOPFBBAP IMIFSEFd/JT Ems, INCE WRN BAN /- n7 0 CT' _AarIJ lJnO _PARCEL MZVAMB <_ _A_.__✓_�, mc'�L-r l.o ADDRE.. C�---� `I S3ao PHONE E 47!6'I3z GAINER'S NAMf - C /� p .�,Fyy COMPACTOR AE/hn l.Y OLL=E7 CY J7 AOd1FB8,�'O✓J C^ 1 ��M NT I1C14/�17{ RNINEB-1(/�.SJEE7 BVB COMTMCTOP F AWxees T•TCN T rvr ME PHONES TYFF OF WEWPUMP; ❑NPN N'£LL ❑REPACEMENT WELL ❑MONROPoNO N'ELLI ❑OTHER /J ❑INB,,A.WTTRION ❑WELL SYSTEM WAS, ❑CRXHU C.NNECT REPAIR ❑VAPOR EMTMCT ON W B � SL/Q Wl.6C/ OMwv Vfl.o.N H.P.�(.{Q DEPTH PIMP SET�fT. NNTWATER--4yL O RYFf OFR1MPI t ✓ • ❑ BOIL WNW / (� _��^ �•.r/) ❑OUTOFRRV E VNEU- ❑MORIYBICAL MUL F I`❑I.EE'BFRVCTbN:W`� INTENDED OEE YPE OF WELL CONBTROCTIOX SPECIFICATIONS A ❑IND RAL ❑OIEN BOTTOM D.A.OF WELL EXCAVATION DIA.OFCONOUCTOPCAMNO O OOMEBTIC/RYVATE ❑GRAVEL PACKOFFE T YPE OF CAMNGRYTEEVPVC DIA.OF WELL CASINO 0 ❑F,RNCA,wMCG,AL 0UFY E. DEPTH OF OROIR REAL M£CIFKATON IF ❑IMOAFIO.. 13 OTHER OIgUF REAL IHBTANED BY GROW MUSED NAME E ❑MONROR. OPOVF.FAL PIMPED:O. O ❑N. s APPROX.DEPTH LOCRNIO CHESTER BOXXROVE RPE / PIOFOMD CONBTRUCnO,,,MUW METWO: MUD MTANY AIR MTARV AMEN CARIE OTHER ND I NE^£iY CERFNY THAT 1 HAVE 1TEPANiID WE'APPMATNIN ANO THAT WE WOFR VML BE DONE M ACCOMANCE WRN BAN MRW W THAT IN HE PERINCEB.STATE LRAM.AND PULES CH REGULATION OF THE SAN MAWIN COUNTY.HOME OVMER ORMODEST AOEM'B SIGNATURE CENTIME THE iOLLOVMIO:'I CERTIFY THAT IN THE P:PFO PRANCE OF THE VATRL Pofl WHKN THIS KRAFT I.ISSUED.I SMALL NOT ENIM Y PERED..SUBJECT TO WMIRMAN'S COMPEXBATMN A.OF CALIFORNIA.-CONTRACTOR'S HONG OR SUSLONfR.CTINO MR-ATNF CENTESES THE FOLLOWING: -1 CERTIFY THAT IN THE FFF60PMAME OF THE MW FON MMICH THIS PERMIT IB MEVE0.1 SHALL EMPLOY PERSONS SUBJECT TO WORMAAN'F COMRNNTMX LAWS OF CAUFIXXPA.jl'ANT MUST CA1lHNOW IN OVAM.FON ALL......�JM XAS AT DECOR 400.N22.COMPETE DRAWING AT LOWER APER RONMO. 41 -PIX `J !� iul. A�e��'7l N ) mu 7^Q�fl ROT PAN IN_1.hN.1 R.C. NAMES OF STREETS ON MADE NEAREST TO OR BOUNOINO THE IN OTERTY. .. LOCATION OF MUSE REWAOE DISPOSAL SYSTEM ON PMPoMO 3. OUTLINE OF THE POPERTY,MVMO DIMENSIONS AND NORTH INFECTION. EXPANSION FSEWAGEOIRM SALJS OF ON J. DIMENSIONED OUTLMFS AND LOCATON OF ALL E%IETIM AND POMRED S. LOCATION OF WELLS WITHIN RADIUS OF ONE NVNOMO FIFTY R. STRICTURES,INCLUDING COVERED AREAS SUCH AS PATIO.,DNVEWAYB.AND WAL%B. ON THE P11MKA,OP ADJOINING PROPERTY. FFn Q W U � I . ;•e1i Uti EY4+ NOV 19 1996 SAN JOAOUIN GGIJNTI —PeeLA)A/Lj Jzb UBLIGHEALTH SERVICLS /�,—T� bq0 -NVIRONMENTAL HEALTH DIVISIO,, `61 QnW n OEPMITMExT WE ONLY APPn,.n.n AL. A—.PI.e OF D.R. G ra/97 mum In.Pmnnn er PRmPI:NPs11eN BY mt. DSI:WnP.I�.P.enen ar c.mm AccONxnxO ONLY: Alm FACE PE CODES FEE INFO AMOUNT PFABTTEO NEC KA.N PECDVID EY DATE PfFWITMFAVICF NEOVFIT XLMe01 INVOICE O, c� a o3salo