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APPLICATION FOR WELL/PUMP PERM 1 SAI _ JAOUIN COUNTY PUBLIC HEALTH SEF`:ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABEE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED vfvj JOAQUIN COUNTY AGOG LMADE TO H U BAN JOACHARTER 9.1 COUNTY fOn A PERMIT TO CONSTRUCTMNDMIT INSTALL THE WORK DESCRIMO.THIS AA'LICAIION IR MADE IN CGMAIMICE WAIT SAN JOAOUIN COVNFV OFVELOI'/MEM TgtE,C`IIA11PTER 81116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC IIIEALTU SITIVICER,ENVIRONMENTAL IIEALTII OMRION, JOB ADDmeamR AP/1 (I(JTaI G_ /Jbl.t�evfy-t�, CITY�h L2�-C.0-E + kaC� PARCEL SIMARD, OWHFR'S NAME /I� TLy .Y-T.7yy{P� J l 1 ATONES CONTRACTOR L^f .r iv �u,�7-. �(j ADDRESS�d T�. 4 6' 424/S;tA UDR//- '] 3 A10NE S� C-96,1 C RUSCOERSACTOR L� `~i"A`�- ADDRESS UCS ATONE I TYPE OF WELI/PUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTINR ❑ WSTMIATMN ❑ WELL SYSTEM MPAIR ❑ CROSS CONNECT REPAIR ❑VAPORESTRACTMN WELL/ J 7YEE or ATMA V— ❑Naw❑n.Pw IT VPE OF N.P. DEPTH Rump S"TE"M T. FIRST WATER LEVEL &Y O n ❑ 0MRRAEl-OIVICE WfLL MOAIYFICAL WELL F ❑ SOS BORING f� rcfl]FTIIIIIRUMLCA . O, -1_ 1?5: ',a�1 B INTENDED WE TYPE OF F� CONtiRUC 110N SPECIFICA IDMS A ❑ IM(HUIM. ❑OPEN Bottom MA.OF WELL EXCAVATION VIA.OF CONDUCTOR CASINO D ❑ DOWSDCMDWATE ❑GRAVEL PACKIRIZE TNTT OF CARIMIRIEELG'VC DIA.OF WELL CARING D ❑ AIDIICRAUNICIIAl ❑pRIVEN MPTII OF GROIN REAL BIECGWATION R ❑ IMMATIONIAO ❑OTHER OROUT REAL INNTALLEO BY GROW BRAND NAME F ❑ MOMTURIM UMUT BEAL AIMMO: ❑Y. [IN. CONCRETE PEDESTAL SY ORK ER;Ely. ❑Ne ,E APPROX.OMH LOCKING CUESTEA SOXMTOVE AlE S PROSOSED CONSMM"ONIOISLUNG METHOD: MUD ROTARY AIR BOTANY AMER CMLE OTHER- 1 IIERFRY CFITT"THAT I HAVE REGRADED THIS APPLICATION AND THAT IRE WORK WILL BE GONE IN ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES.STATE TAWS.AND RULCO AND MGM AlMNS OF THE RAN JOAQUIN COUNTY. HOME OWNED OD LICENSED AOENT'S NIONAIUIIE CfMirit8 THE FOLLOWING:'I CERTIFY THAT IN THE PFFEU MANCE OF THE WO1St TOR W111C11 IIIIR AGMII IR I9911FD,I MSALL NGT EMPLOY PERSONS SUBJECT 70 WORKMAN'S COMPENSATION LAWS Of CALIfORNU.' COMPACTOR'S HIRING OR BUS COMPACTING MONAIUM CERTBNI nIPN01LOVANG: -I CERDFY THAT BI THE PERFORMANCE OF 111E WORK FOD WIIICIT 11115 PMMR IR ISSUED,1 SHALL EMPLOY PERSONS SUBJECT 10 WORKMAN'S COMPENSATION LAWS OF CALIFOMIA.' THE APPLICANT MUST CALL N VOWS IN ADVANCE FOR ALL REGMRED INIPECTIONR AT 12"14S4S4XV. COMPLETE DMWINO AT LOWER AMA PROVIOEO. RipM X Z �� DHP I �� Or AAM IDIµle ReMPI 1leala '\e I. IIAMFN OT SIREFTN OD MMS MFAM§t IO OR POUNDING Tim PROPERTY. 4. LOCATION OF IIOURE BMAOF OIRMSAL SYSTEM On A RED ]. ntI111NF OT tIN fMAgry,GIVING DIMFNSIONN AND NOMII VIRECIMN. EXPANSION Of SEWAGE DISPOSAL RYRIFMS. ?. RIMFNAKINED UMLINfS AND LOCATION OF ALL FXMTIM AND MOMSED S. LOCATION OF WEI Le WITHIN RADIUS OF ONE 110HOMD TIFTY A. BUSICTITEe,WCLUDING COVERED AREAS SUCH AN PAINMS,DRIVEWAYS,ANO WALRB. ON 111E A10PERIY OE ADJOINING AIOMITTY. j 1:'LB : 3 1998 1 hlu Jn'.; I n111 e1vJIROtJM KLIAI HENT IIII, 'ISI )� L. i. .. .. .... N.. J OFPMIMENT USE ONLY AwBegLn Mar..\wl OF C— n.em Imnwnm•E, ate Puny SNpaa\len NY patty G..L,nllen Irsnw.tMn Rv Dala femmmrla � O / ACCOUNTING ONLY: AIRF u I FACE PE CODES FEE INFO AMOUNT REMITTED CHECKS ASN RECEIVED BY DATE PEIWIITMERVICE REOUESTN BFA INVOICE B X0 i Pub Health Serv.-Enviro.173(1/97)