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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAN JOAQUIN ST, STOCKTON,CA 96201-388 KS 708 ZO-W66-101.COO 1 <br /> 120914683420 -rh-6 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM RATE ISSUED <br /> ICBmpIIW in TF41iutEl <br /> APRKATWN 16 HERE SY MADE TO THE 6.W JOAQUIN COURT Y FOR A PERMIT TO CONSTRUCT ANUMA INSTALL THE WOWL DESCRIBED.THIS APRJCATMN 16 MADE IN COMNANCE WITH&W <br /> JOAW W COUNTY OEVEtORAEM TOFF,CHAPTER B-1116.3 ANO THE STANDARDS OF GAN JOAOWN COUNTY RI&RC HEALTH SERVICES.ENVIRONMENTK HEKTN DOWN ON. <br /> JOB ADOPENHO.APRs31.9 Sr.. tftNY q7 Cm .57M94Uu IMCEL Bru <br /> OWNER'S NAME&G-77LYL VRCLCY 57YIr4TFl CJ60�Jn 6ADDING" 10o'&'-A IBZ.O RIOw. YLZ—Z3Aq <br /> CONTRACTOR64--�rfzom �Kc eir.l�LUeR woREe6 Z32S' E mY2rte Sf. uc,, 266 moxE69'1Y-t34S <br /> SUB COMPACTOR ADDRE88 .8 RIDNE I <br /> TYPE OF MUJPIMP: ❑NEW. ❑IERACEMEM WELL ❑MONROWHO N'EllI ❑OTHER <br /> ❑dSTMLATON ❑WSLL SYSTEM REPAIR ❑CR08840NNECT REPAIR ❑VAIOR E%TMCTON WELL 6 J <br /> C).0 pWr N.P. DEPTH PUMP 6ET_l. FIRST WATER LEVFL O <br /> DYPE OF RIMR <br /> ❑OVTOF6EPVICE WELL ❑OEO FNVMCAL WFLLI KY BOIL BOPoN6 J a <br /> Cl OESFRUCTgN: Wl/ BFtGCfi THIOL-, P416 rr I1= 1,4"J 'wnt'5)(L /3.NL(JUN1-P,(LRQ <br /> INTENDED USE TYPE OF WELL CONATRUCPON 6RCIRCATIONE A <br /> ❑INWBTWAL ❑GRN BOTTOM A.OF WFIL EXCAVATION OI A.OF CONDUCTOR CASING O <br /> ❑DOMEBTICPYVATE ❑ONAll PACFJBDE TYPE OF CASIMU EEI dA.OF WELL CASING O <br /> ❑PD.1 MUNICIPAL ❑nnn E. DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑IWYG.TI..lAG ❑OTXEn SMUT SEAL INSTALLED BY 1�I GROUT eMNO NAME E <br /> ❑ GR <br /> MONRONN6 I �J�I OUT6EALRIMRD:❑Y- pLW CONCRETERMWIIE <br /> STALBYOP:CIYM ANO S <br /> ARROX.DEPTH IS 'YD LlJ LOCRINO CHESTER W XISTOVE PERE <br /> MOPoSEO CONETHUCTION/MWNO METHOD: MUD NOTARY .0 ROTARY�AUOER CARIE OTHER <br /> I HERESY CERTFY THAT 1 HAVE PREPARED THH AFRICAT..ANO THAT THE.p POLL BE DONE M ACCOIOANCE MTN MN JOAWIN COVNTY ORDMAHC'E,STATE LAWS,ANO...ANd'a <br /> REGULATIONSOFTHESMIJOAWINCOUGf . HOME ORAHM OR MERGED MEM'8dONATUR CEMIREB THE MI-UAMNG:'ICERTIFY THAT IN THE PERFORMANCE OF THE MW FORWHICH <br /> THIS PERMIT IS ISSUED.I SHALL NOT FMROY RREONB SUBJECT TO WOR M-6 COMPENSATION IAMB OF CAUFOWUA'CONTMGTOP'8 HIRING OR 6UBLOMMCTIM SIGNATURE CERTIFIESO <br /> THE A0,L0M O: -I CINEHN THAT IN THE PERFORMANCE OF THE WOM FOR WHICH THIS PE GUM 18 ISSUED,I SHALL EMROY PERgONS SUBJECT TO WOHOAANY COMPENSATpN IAMB OF <br /> [ALIFOIWM' ry\]�APDL MWiCALL DS MUSE IN ADVANCE FOR ALL ROMEO INSHINCERNISS AT I309140Ri�Sa/6..COMPETE DRUMM AT LOWER AREA RODDED. <br /> SI6r�SA �L> �aAu T. <br /> NUIT RUN 03—IB S l SOBS <br /> I. NAMES OF STREETS OR MADE NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF MUSE SEWAGE d6Po8K SYSTEM OR PROMO <br /> 3, OURINE OF THE PRD O,SMUG dMENI ONS AND MRH DIRECTION. EXPMJBION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. OIMENSONED AND O WCATOTIN <br /> N OF ALL EXISTING AND PROPOSED S.LOCATION OF WELL8 WTIIN RADIUS OF ONE HUNDRED HFTY FT. <br /> STRUCTURES,INCLUENNO COVERED AREAS SUCH AS PATOS,MS AYS.AND WALKS. ON THE PROPERTY OR ADJOINING RORMY. <br /> I <br /> 1111` <br /> C <br /> PfiLPaSF-� LLAG� d'Myil/EN <br /> E� 'MI-14ab RFCL-:jVED <br /> srP �Maz MAR 2 8 1.4,05 <br /> �- ' Io�plllraalurdr <br /> � � f �J 61C HIrAI lI r ,Vlf <br /> T <br /> ®�P2a4 P,aYLati6S <br /> / oMARTMFEIT WE Ox\rI <br /> AopllnB.n A„IPrM Br D.M 3 Ab ?L A,M <br /> c,wn l,.P.eSerr Br DPM Wnv M+BVIBE OMS <br /> D�rrlcrHrr BwsHen Br n'� gtOK La � ' L DMB <br /> lloo <br /> AccauxnnG OxLr: Mw FACA <br />