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APPLICATION FOR WELLIPUMP PERMIT `SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EAST WEBER AVENUE. STOCKTON, CA 95201388 QUM 4693420 NUIE-REFURDARLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICBmi In Trllrlle°l.l APRICATION IN AIRF N4 MADE TO THE BAN JOAGOIN C,OUMY FOn A ITMAIT TO CONI ITIIHCT ANPgn INFTAI L TIIE WOW DPRI:Fii THIS AATCAIION IS MME IN COMMIANCE WRIT BAN JOAOUIN COUNTY DEVFLOPMEEHY TT DI F.QIAMFfJJnJJJ�//8�../��-11116.33 Agym THE FIAIINAAOe'IF NAN JOAOIITN Y'.n11W Y M;nnl l�f,(I/HIf,AM III y°ESOVIC.FB,FEIVIRONME MALI HF TIN TMBmN. JON ADDREBRon APHI�5�/-�F,I,e=��J � ___/�.. __.......-..__...___CU♦ ✓Tv Y��:l_ S-f OWIRR'B NAME �1/vlt�y/JJ�O M ___ADDIV fn-6-9-- ��._�_ 9 AroNEIQ,�,c i CONTRACTOR jmll O� dr /I "y -AbOnina�C,_Q�X�1- INC.1c?Wj" AIONF F� BUB CONTRACTOR yam. J— AGnIRI Fn__. _._ -Y'- IICI AIONEI TYPE OF WELVAIMN, BO ZV WELL ❑ MMACFMCM WEIt ❑ MGMT0A,N9 WFIT./ ❑ OTiOn ❑ INSTALLATION ❑ WELL SYSTEM r1i ❑ CROnBCONNMT MrAIR ❑ VAPOR EXTRACTION WELL I J ��.// / II IETNRv❑np.b ILP. GFr411 PIMP ET tT. fIRBT WATER LEVEL /�D IF O ^^ PYP OF MMPI -F-- O� ❑ OUT Or-BERICE WELL ❑ MOMYMC.AL WEI L I ❑ FOIL RONNO n d ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION BPECNICAIIONA - - ❑ INDUSTMAI 1RE❑�AE ORN flo"OM /E DIA.OF WELLEXCAVATmEI '(/I DIA.OF CONnUCTOR CARINA II DOMESTICRYUVAiE yy GRAVEL PACK/PTE _ TYR AI MFINO)FTECI/INC f!C CIA.OF VJFLI CABiNn p ❑ NRUC/MUNICIPAL ❑DRIVER pElTll Of OAOIT SEAL O f-�-- SPECIFICATION /J5 ❑ IRRIGATIONIAG ❑OTHER GROUt BEAT INGTAH EO RY__�p, GnO1R BRAND NAME (I 0Ar�1P ❑ MONITOmmo G�,�S OF GROAT FEAR MCJtM110: vy- BO%N. ATE CONCRETE PEDESTAL BY MILLER: Y-Y- ❑Ne S� APAIO%.DFPfN �/ 5 PROPOSED CONST MnORn LUNG METHOD: MUD NOTARY A AIR°OTMY ALIC.fR CMIE OTHER I HEREAT CERTIFY THAT I HAVE FMPAR.THIN AFRJCATION AND THAT THE WOW VAIL BE GONE IN ACCORDANCE MTN BAN JOAOUIN COUNTY ORDINANCES,STATE"We.AND RULES ANO MOULATIONN OF THE BAN JOAOUM COUNTY. HOME OWNER OR LICENSED MFNT'R SIONATUM CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN TNM PERFORMANCE OF THE WOM FOR WHICH THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY RR80N8 SUBJECT TO WOMMAN'S COMPENSATION LANG Or CMNOnNIA.' COMRACTOA'B AIRING OR SUB CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: -1 CENTIFY THAT IN THE PERFORMANCE OF THE WOW FOR MlIC14 THIS PEBLIR IB IONUEo,1 NHALL tMROY TIMMONS SUBJECT TO WORmNAN'S COMPENSATION LAWS OF CAUroMBA.' TIIE N UGN M BT CALL 24 rgU1B IN ADVANCE FOB ALL REOUn%p INSFEOTIONS AT 120B14BB.HX1. COMREtE D(IAWING AT LOWER ARA 1`ROIDED. n-7 RlpraB X F �>7� IMP/')� D.I. .3-3- 7 / ROT FUN m,m•to NeH,I Y.Iw -In t. NAMES OF TRFTB OA ROADN NEARBT TO OR ROUNDING TNF P10fEnTY, 4. LOCATION OF HOUSE SEWAGE INAPOSAI,BYBTEM On rOnMHMD 2. OUTLINE Of THE(OORRTY,GANG DIMENSIONS AND NORTH UIRECIInN, EXPANNION OF SEWAGE DISPOSAL BYNTEMB. J. DIMENSIONED OUTLINE°AND LOCATION OF ALL EXISTING AND PROMFro N. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY fT. NTRUCTURS,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAY&,AND PIAMI. ON THE PRORATY OO ADJOINING PROPERTY. HArAhter LArC j � LCarV� L :Y11° � M , N 1 I� Qzs,I, W m "9 it> � S ;YAK. 7 19 ii PUBLIC HEP.LT, ENVIRONMRvTaI LI Ll TL4 DEPARTMENT USE ONLY - AppllcHlen A-I,rI l Br L�L(�`�✓ title N.eI_/ G.w hppecrlsn er /iA/,' D.I. // T+7..p tl..nKnpn Br .n V�9lr/7 (� D.1. Osbmllen 1 neemn Flv _ _ � ��l / / e n Dete Cemm.,lF: ��p / t 6e.SFNe /A1CK..G/Gr✓ uu�i� DCI w�L.P�e ui_r7 Gy�//•y i( I (.o lY��CJJE��wJ/ -J/7C/1 /Jf ACCOUNTING ONLY: NDE FACE Ky" tiJ�` R COD" FEEINFO I A MT BEABtim C11EC ABH AECOVCO BY DATE PBOMITMETIVICE REQUEST NUMBER INVOICE O �fs4 L6 3hlq all 7 99 03587 V� O SO _ 035800 Pub.Health Saw.-Enviro, 173(3/96) (i ,1a,,F14-7