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APPLICATION FOR WELLIPUMP PERMIT \v`'b <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SEh ES ©o s637 <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br />(209( 469-3420 <br />RON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />McWiBtB Y TTIP6noF) <br />APPVCATION M IIEAE BY MADE TO THE SAN JOAOUN COUNTY FOR A PEWAT TO CONSTRM;T RR O NSTA T MW OESCNBEO. THIS APPMAMN IS lEADE IN COMRIANCE WBII S. <br />_ JOAOVN COUNTY OEVELOPMBIT TTTIE, CHAPTE/%I H-1115.3 Rtc, TIE ISTRImOR OS OF BAN JOAWIN COINTY PUBM WEALTH SFAVICES. EtNIRONMEtNAI MIA TH DIVISION. <br />JOB AOOIESSgq/IA��PN. 99 0 C��,-A <br />Rd PARCEL 6RE/APa( <br />OWHEIi'S NAMEJ'(A NL �AL-I L•rLr NPMF S AOrnEss�Oo Cgcjsy AtcdAy i LA � 5�/tWDEE►7/i-S_12��i <br />CONTRACTOR&)Qi2c1S oe// Dei lb- AOONFoo eo- 8.nr 337 14 EeA C A- m# ?82$Y4 G,im E IF -745-2 L <br />BUS CONTRACTOR ADDRESS MR BANE <br />TYPE OF wEtulwlAr: �WIFW wEu ❑11EPtACEAENT WETL ❑MOMToWNO WETL6 ❑OTHER <br />I ❑ NSTALLATNRS ❑ VALL SYSTEAS IFPAIN ❑ CIASSCONNECT 11FPAN ❑ VAPOR EXTRACTAN WEu <br />Sun ❑N os - ". 02 'r DEpIH SET FT. FIRST WATER tFV9. <br />_ RYPE Of PUMP) <br />❑ oDTOFbTTWICE WEu ❑ DEowTYi1CAL WEu • ❑ 6oN Row <br />n f <br />_ INTENDED U6E <br />TYFE OF WELL <br />CGN6TRUCTAN BPECNECATIONS <br />, <br />❑ NOIISTNAL <br />wTrOM <br />DIA. OF WELL EXCAVATAN /.1 <br />DIA. OF COE✓DIICTONCASIPNQp 4/0..1/4� <br />DOMESTICIPI\VATE <br />10OPEN <br />❑ SHAVO. PAtl(/SQE <br />TYPEOFCASR� _mac' E� <br />DIIL OF WELL CA O4 <br />❑PIIBIx:w,RNacpAL <br />❑IRBVEfW <br />OET'fH aF O110Uf SEAL �V ll t <br />wECNTCAT1tlN <br />- ❑IRRKIATMIWAG <br />❑oTE1FA <br />I:RDIrT SEAL NSTAl1ID IIY%. �M�. L/F/l DA1///AgcrolTr <br />eRALWO NAME 95AcK� 1 <br />❑ MONTORRIG <br />GRDUT 6EAl PVI.atU ❑Yr ❑Ne <br />AS4N(♦ <br />CONCIFTE PEOE6TAL NY DI6UHt CTYr ❑Ne <br />1LOCKING <br />ARF x 6 <br />0 <br />CIIESTEA IA%/HTOVE PEf <br />, <br />PROPUB® CONSTRUCTIONAMLLINO METHOD: MUD ROTARY <br />AIR ROTARY AUGER <br />y <br />CASES i OTHER <br />1 IIE�FJIY CERTEY TIIIAT 1 NAVE FIEDAIFD TMS AWRWCATIOR ANO THAT THE WO1B( WLL N DONE N MCORpANCE WIHI BIN JOAOUN COUNTY OIANNCES. STATE LAWS, AND MILES N <br />REGIAATANS OF TIE 8AM JOAOUN COUNTY. NOES OWNEA OR UCE1i6E0 AOFM'8 6N:NATUIE CFIRRE6 TIE FOIL04NlO: •I CERTEY THAT N TM: PEIEOfE1NWCE OF THE W01EC FON TNlll <br />TMS PEIWIR W 16611®. 1 SWLLL EAT EAiLOY PE1160N5 6 CT TO WCgGAAWS COM SATICN LAWS OF CAIEOIWA.• CONTRACTOfl'S IINBIID OR SIN CONTRACTNO 6,,,ATUM CERTBI <br />THE FOLL I: • 1 CERTFY TiIAT N TE PERFONAINAE OF THE WOp( Fdt WIWICJt TMB PENH/ M 186UE0. 1 BIIML EAiIOY PEIIBONS SUBJECT TO WORAAAM'i COA*BIBAl10N LAWS <br />CAIIFOFI T A)/RRM^11 F FR"T CALL N ADVANCE FOR ALL WEQAAR� NBRRCTIOW AZW <br />WT tIOENtETE -NB�JE3-1. CORiA N AT LO AIFA ggVNIED. <br />6lo, x I�/ Xl W TIB._ <br />wnr laww A..,N m erly ie�l. • m <br />1. NAMES OF STREETS OR WADS NFAIEST TO OR IAI/IPA THE PRDP9ITY- 4. LOCATpN OF IAUBC SEWAGE DISPOSAL SYSTEM OR R RASED <br />2. 011TtllE OT TIRE PROFORY, ONINO OMEN6AN6 AND INIRTII DNECiIdI. "PAN&ON OF SEWAGE MBPOSAI- SYSTEMS. <br />O. WI.IENSIOlIFD OVTHIIEi AIA LOCATAN OF ALL FXI6TRWG AHD P11OPD6EU 6. LOCATION OF WELLS VYRMII RADIUS OF ONE IlI1NOIEO FIFTY FT. <br />6TMKTURES, NCIIANO COV AP[AS SUCH AS PATKM. DRIVEWAYS, AFA WAIXS. ON TIE PROPOITY Oft ADJ PROPERTY. <br />