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APPLICATION FOR WELIJPUMP PERMIT <br /> SAN JOARUIX COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O Box 388.304 EAST wEem AVENUE,STMKTON,CA 96201,988 <br /> ( 484.3470 f/r1 <br /> M014REFUN0�9LE PERMIT <br /> IT EXPIRE!1 T AIt FIIO ORTE{ 8UE0 <br /> ICsm�IB11 ID Tr1QGau) 1 <br /> APPLICATION IF HERE BY MAbE 70 THE SM JCAOUW COUNTY FTIR A PFrMT TO CONFTRUCT AHDf n INSTALL 1HE Wow bEXCRSFO.THIS APPLICATIOH IS MADE IN CoUrUANCE WHIZ BAN <br /> JOAODIN COUNTY DEVFLOPMENT TITLE,CHAPTER 9-1118.3,�ppN6 THE ETANOARDE NN <br /> OF BAN JOAOUIN COUNTY PUBLIC IEALiII SERVICES,ERONMENTAL HEALTH DMBKM. <br /> JOO AOOREBSILITFUMA LA C1T'd / PARCEL lEl. <br /> OWNTNO NAME ADDRESS w A'tti FIIdNc• <br /> COWRACTOn L� ADOREEF U[3c9�31_FyIUMEI� � <br /> auR CEMTMCTOR_PftwV F ADDRFM Licefin, i <br /> Tm of WELIIP w ❑HELY WELL ❑RIRACEMENT WELL ❑AwNAOmkOVYFLl7 ❑OTHER <br /> INSTALLATION �1---1-11 rINSTAINSTALLATION ❑ <br /> T <br /> N WELL SYSTEM REPMR 1- CROSB-CONHECT REPAIR ❑VAPOR EXTRACTION MEN <br /> ��Li��(.j{F,•L� ❑N X-- H.P. DEPTH NNP SET__FT_ "NIST WATER LEVEL O <br /> YPER OF PVAFFI �-�1 <br /> 0 OU7-OF SERVICE WELL ❑OEOFYIYSFCAI WELL R C7 SOF.BORNO S <br /> ©I)EerFNCT1ONr <br /> IMTEH_Dm UFf !-Y1 OF Wql CONSTRUCT1oR aFECIMA11ONS A <br /> ❑1--F ITgUETmAL E3 OPEN SOTTOM DIA.OF WELL EXCAVATION SIA.OFCONDUCToR CASINO D <br /> 0 OOMERTICBWVATE IJ DRAWL PACKAH"E TVPE OF CABINORTFRA'VC OA.OF VELI CASNO O <br /> ❑F--I MAICRIIUNICIPAL ❑DRIVEN DET`TH OF OROUI SEAL T.FSSIexATION R <br /> 0 RtSGATOLSAO ❑OTHER 011OUT SEAL PSETAlLE0 DY OHOUT OMNI)NAME <br /> ❑N0PRTOAN4 OROUT JFALPUMRl O:❑Yw ❑/7. CONC1fk rE IEMaTAL EY DwLLEfE❑Yw ON. ; <br /> APPROX.DEPTH LOCXINU CIIESIER BO)mE`VE APE E <br /> PROPS/ED CONSTRLICl1ON,DplURO M/Tllob:A1110 pDTARY MR RDTARY AUOFR CABIF 1D7NE/1 <br /> I HEAEOY CFRTFYTHAT I HAVE PREPARED THI6 APFUCATFON AND THAT THE MAX WILL BE BONE N ACCOFDAHCF WII N SAN JOAODIN COUNTY ORDINANCES,STATE LAWS.ARD RTIAFB ANp <br /> REOInATbNF OP TN[BALM JOAOUN COVITf'Y,NM4F OWIrtR dR IICENFEO AOENf-2 SIGNATURE CERTIFIES THE POLLOWINO;'1 CEMIFY THAI IN THE fE1rORMANCE OF THE WORT FOR <br /> THIS PFRAOT RIBOUED.I SHALL NOT EMPLOY PERSONS RUB7ECT TO WOMMAWSCOMPFN1AT10M LAWS OF CALNT]DAA;COTE MCTOR'S IImm OR N,S4'DFRRACTNo 6NNATURE CE14T <br /> THE FOUDWNS{ -1 CIFH`ry THAT N TIRE'FEnFO1MAHCE OF THE W(MR FOR WIIWH 111411 PEg71T R ISSUED,I NU1LL"A"V PERSONS OLI6JECT TO WO1UDfA0'O COM►WlA71LR LAW/OF <br /> [ALVOIMA.- Tii GAR /TCR 27 NOIR/NADVANCEFDA AV,REOIFIIEO IM TIORS AT 1'/17.34121.COMTLETEOMWNA AT LDNIER AREA""VIDEO. <br /> 1 <br /> BawdX <br /> ROT 11.AM OAAw H SVMA1 SaAI. '!b - <br /> 1.RAMEB OF STREETS OR FIOAbS NEAREST TO OR ROUMM TIRE POOKITTY. J 7,LOCATIONOF/ROUSE SEWAGE DISPOSAL EYETF/A OR I,IOPOOEb <br /> 7.OUTLINE OF THE PMPERiY.0W WI OVAFMMHB AND NORTH ORECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEMB. <br /> 7.INMETHHOFEO OUTLORRA AND LOCATION OF ALL EXIBTINO AND PROPOSED S.LOCATION OF WELLS WITFmI RAOMB OF DINE HUNMD F6TY h. <br /> STRUCTIIFILG,INCLLMNO COVERED AREA■SUCH AS PATIOS,DRIVEWAYS,AND WALX6. ON TIE PROPERTY OR ADA7RRNS PROPERTY. <br /> ICU E E 1 <br /> AR 18 1997 <br /> 'A ;,q it :: <br /> EN6gR N EN7Ar_HEAL7N plh&' <br /> ON— <br /> _ OE►AATMW T USE ONLY <br /> APHlwllen 0l.,l ST ON. A. <br /> d.0 bbpelden MAL PMb P. Inp.OlOn Sy <br /> oa.luelMn tr_.ehn��OyY�1_ <br /> Ew,VnwR�:_O_ EJ <br /> AG[OUN TINS aALr; ARN FAC. <br /> FB COOEA FEE INFO AMOUNT F"MilEL IEC KAlH nECOV ST LATE POEVFTl6EFIVICF RFDIRSI RUmIft INVOICE <br /> Pub.1leahh Serv.-EMIro.173(3196) <br />