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APPLICATION FOR WELLIPUMP PERMIT 41�rJ JOAQUIN COUNTY PUBLIC HEALTH SERVICES•o ENVIRONMENTAL HEALTH DIVISION P,O, BOX W. 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (2091461-3420 /� NON-REFUNDABLE PERMIT EXPIRES 1 jqR FROM DATE ISSUED / 1FNIANCYF , Walloplate AM'LICAI ION IRIIFME RY MADE TO 111E RAN JOAOUfN COUNTY rOn A rEnFA1T TO CONRTTnUrTI AND/OR INSTAIL 1HF.WORK I)FFCnIF1FD.THIS AMICA R M1` l CN JOAQUIN COUNTY OEVELOrwE/Nt TITLE,CIIAPTF.n A-1 1 18.3 AND TIIE 81ANDARGR or RAN JOAOUIN COUNTY 8141IC IIFA1.t11 AEnViCFS,ENVIPION0.IFNT AL IIFALTII DIV, N. JOn AOnrFSR/On APNI 3I PI ?nsfr I r"O] m, CITY- r Nw. Or y � A ICI 1117F/ANI& �f- OWNEn'R NAMF ft �at U /j.r!!S•r_J.- A110nFRR » mIONF CONI MC1On ��I �,�I�I��IL(Ll/�/ AbbnFRR �_ T; 1-�- • Jr. --- L �" Pf IONEE/I 'Y-5 PVPCONTSAmon_ V'T-yt,/ (a GIJ� ,wISI ., �f,' L,, AOOnFRR_ i6 int Sr-A I G- t,71 LMI r inw o, 2-S TYPE OF WELL/MMP: ❑ NEW WELL ❑ nfrLACEMfNt WFIL ❑ MONITOnlNn WFIL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CnORR-CONNFCT REPAIR ❑ VAPOn EXTRACTION WELL J IJ n—El nwpelr H.P. flFPlll r1MP Rrt FT. ►InBT WATER LEVEL 361 Vr'f OF MMPI /lQ J _` tnO Cl Otto or'RvICF writ. I� Om IVrICAl Wfll I � Ron aoroNO/r 1C tCu_yIK„ ❑bEFInVCIION: �_ _ INTENDED USE TYPE OF WELL CON6iRlK:110N SPECIFICA PONE -- - ---- - - - ❑ INDUrTn1AL ❑OPEN NOfTOM DIA.OF WFIM .L FXCAVAT N u r l /7 ___ C DIA.Or CONGUCIOn CARING J� 1, ❑ DOMERTIC/PRIVA'IE GRAVEL PACKIRIZE a,'3 sh►I9 TYrf OF CASINO/RIFFT/PVC�1_ A�y� DIA.or WFII CAe1NO__Z If R FJPURLIr.IMUNICIPAL ❑nmVEN nFtrl 11 OF OnOUT REAL_ hr jT RPECirICATION-Q. Q��T ✓C� R ❑ InRIOM10NM0 ❑Ot11EnGROUT REAL RTBT AHED BY OROI/T BRAND NAME F �I MONlinnINO OnOUT SEAL PUMPED: ❑Ye. ❑No CONCnFTE PEDESTAL BY DIVLLER:[I Y. jou. g •rPnO X.OFITH 19 LOCKING Moral too SOX/MOVE PIPE $(C't A-,rr *Ite) acTY-1Y - fnOPOSED CONS TRUC TIONIONLUNO METHOD: MUD ROtARY Aln ROTARY ^ AIIOER CABLE 0111En �•��•�s I IIE9FRY CERTIFY TIIAT I IIAVE PnFPAnFD TIIIB AIYLICATION AND TIIAT 114F WorW WILL aE GONE IN ACCOnDANCE%AIH RAN JOAQUIN COUNTY OnOINANCF.S,RTAf F 1 AWS•ANO nIrLFR AN I HD nE0ULATIONR OF TIIE SAN JOAOUIN COUNTY. HOME owlim On LICENSEO Anmt'B BXTNATUPIF.Cf RTIrms TTomroILOWINO:'I CERTIFY TIIAT IN TIIE P4RrORMANCE OF TIIE WOPIK FOM WMCi1 IR PEnMIT IR 1R8UED,I RIIAI.L NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Or CALIronN1A.' CONTRACTOWN InnVNG On RUB-COIJIRACIINO SIONATUnE CEIfI1r1ER 111E fOLLOWINO: 1 CERTIFY TIIAT iN TIIE 1ERFORMANCE OF T11E VVOIVL POM WHICH TIIIB PEMMIT IR ISRUED.1 SHALL EMPLOY PEnRONa lTU"JFCT TO WORKMAN'S COMPENSATION LAWS Or CALIFOnN1A.' FIE APP'UC NT MUST LL 24 1N ADVANCE FOR ALL REOUIREO INSPECTION*AT 12..00911 4SS-36422. COMPLETE DR AWING AT IOwER AnEA PRO DFD. alpnwd X TRI.- `j _ I rli4 J Gtr 1Z-�J(11�'L4:+tL D.tw_ t: PLOT MAN IGr.-to Seel.)Ro.l. 1. NAMF8 Or RtrwFTR On nOADR NEAnFST t0 On BOUNOINO IIIE PIIOrEnTY. 4. LOCATION OF IIDURF RFWAGE DISPOSAL SYSTEM On rnnro Rfo 7. OI1t im OF THE PROPERTY,GIVING DIMENSIONS AND NOnTH otnFC110N. EXPANSION OF REWAOE D18PORAL RYRI EMS. 8. DIMENSIONED OUITLINf.B AND LOCATION Of ALL EXISTING ANO PnoPORF.O S. LOCATION OF WFLL8 W"I"N RAO1114 Or ONE/IUNDnEO rorty FT. STRUCTURES,INCLUDING COVERED AREAS BUCH AB PATIOS,DfVVEWAYR,ANn WALKS. ON 111E IROPERTY On ADJOINING PnnMntY. tx(Al I I 1 � I f��fiEiCMk-nf�✓' DEPMTMFNT USE ONLY Applleellprr A...prwA ay <O .r T _ arrnn In•nwcrl•.r,Itr _ Getw (p �U _�Iy mrp In•nrw.riwn Sy.,____.___.-_—._._.-_ nweirtnlleO Irwpw!Ilrm By Commwrgr -ACCOVN HqO W11-Y! 1 /SIG/ - PACT PF.CODES rfE INFO AMOUNT REM111ED CIK.CXIICASII MECEIVF.G NY DATE P IMOT/SFPUVICE RFOUEST NUMBER INVOICE (, � - - ---- — — -- 7 �'c Pub.Heahh Serv.-Enviro 173(3/96)