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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 389.904 EAST WEBER AVENUE,STOCI(TON,CA 9501388 <br /> (209) /01.3420 <br /> NOWREFOR9A91E PERM DWIOES 1 YEAR FROjA DALE IfRUE9 <br /> rAmpIStB Is TrlrRall) <br /> AfRICATIOEI N ITER BY MADE TO THE BM JOAOUW COUNTY FOR A PERMIT TO CONSTRICT ANDIOR INSTALL THE MARK DENCRIDED.TIME APPLICATION M LEMS N COAFEJANCE WITH BAN <br /> JOAOUN COUNTY DEVELOPMENT TILE.CHAFFER B-11 I 1 6.3 AND THE STAND 1ARD9 OF BAN JOAOUIN COUNTY PUam HEALTH SERM"o.FNVNbNMNTAL HEALTH DMMON. <br /> JOB ADORE.APNJ II Li (J �('r_A (J_f+� CRy �/C.� PAACEL lWMAPH._ <br /> OVM.ER'B RIAAEET 'f0►" ADORES! Po h 1l all 1�Tra cY FIwNE. CJ��F�S�.Lp� /TU <br /> COMRACTOII ' r . G. ADdESt �D�C 1E0 PL'}CE u y± g6�ppFa;, <br /> M COMPACTOR ADOREae LJCB -_PHONE, rr <br /> TYPE PF WELLIPUMP. ❑NEW WELL ❑REPLACEMENT WELL ❑MONRORRT WELL I ❑OTHER <br /> ❑"T"O" ❑WELL�'STYaiEM REPAl11 ❑CROSS,ONNECT PWAII ❑VAPOR ORRACT00"VEILI <br /> sub ❑u.-Ll n_.b H.P. -C Q DEPTH <br /> R1PAP SET <br /> R. RRBT WATFR LF TL p <br /> II WE OF PwFI —� <br /> ❑OIR.OP BEAVICE WFLL ❑OEOMIYMAL WELL I ❑ BOK IIOR•O , <br /> ❑DFaTRXTkW: <br /> O <br /> T CONaTRUC ION RVECIHCATION-r A <br /> ❑❑�NOUBTTBAL []OPEN MITTOM DLl OE WELL EXCAVATION dA.Of C09AXWTOM CAMMO 0 <br /> FP'l ESTK:lMVATE ❑GRAVEL PACK/STE TYPE Of CAMM?6TEElA'VC ON.OF WELL CASINO 0 <br /> ClPURLICPMUMUP <br /> CAL 13ORaVEN DEPTH OF GROUT SEAL BiIECIFICATpN R <br /> ❑PWGATpIVAG ❑07HEII GROUT BEAL INSTALLED BY OEOUT BRAND NAME E 1� <br /> ❑LKTNRORNG GROUT—RIMPEO:❑Y. ❑N. CONCRETE P"**,AL aY DRLLER❑Y. ❑N. S <br /> AFPROX.DEPTH ("DKV CHESTER BOXMTOVE RIE— a <br /> rI10FOI®CONaTRUCTONA]I"U"a LEBTHOO: MUD ROTARY-_AIR ROTARY AUOER _CABLE OTHER (- <br /> 1 WW RY CEATFY THAT I HAW PRP/VEO TMS AER1CATpN AND 1HAT TRIE Ys01R ROU.BE DONE N ACCORDANCE MRF"BAN JOA—COUNTY 01bINANCEI,07117E—1,AND RLKEB AND <br /> ROUI.ATbNS C <br /> Of THF IAN"A"""COUNTY,NOME—m OA-,-,oO AGENT'S—AT—CERT-FI THE PoLLO'AAO:'1 CERTIFY THAT M THE PFWORAANCE OF TIM WOR(FOR WHICH <br /> 71N PF1MR IB IISUED.1 SHALL NOT EMPLOY"Moos,IUIJECT TO WORIMAN'S COPMIORATION LAWN OF CALFOFIU.'CONTRACTOR-11-11IaR110 OR BUB-COMIIACTNO BIONATUFB! H[FFIES <br /> TIE FOIIOWNO: 'I CERTIFY THAT N THE PERPOIMIANCE OF THE WOR'FOR WHICN THIS PLRMR R RBUED.19"BHALL EMPLOY MINIONS S1RJ[CT TO MLMIIGMAKS COMPdIAT10N UW B Of <br /> CALlFO01F111' TJE•EPfUCAMT aR1B/'CALL N NOt11M NIANcf POLI Alt TRIOIBREp J TpNa AT 1 2B,�COMPLETE AT LON411 DAINEA <br /> `a(-J�dL]6- t�7 y/6S�il� PLOT PLM P.- <br /> 1.NALFES OF ITEETS OR ROAOI NEAREST TO OR BOLNONO THE RgfEATY. �. LOCATONOF HOUIE 911V"F"WOBAL BY-,"OR FIOI'OBEO <br /> 2.OUTLINE OF TTM PROPERTY.OWING DMLMMONB AND NORTH DIRO <br /> CTN. EXPANMON OF GWWAOE UPi WAL BYSIFMB. <br /> 7.OFAENBIONEO OUTLINES AND LOCATION OF ALL EXNRR/O AM PgDFD@EO a, LOCATION Of WELLS WI-MIN NORM Of ONE"L%SO1EO F117Y FT. <br /> BTRICTU MS.INCLU SAND COVERED AREAS SUCH AS T'ATIDB•DRVFWAYB.AND WALA I. ON THE PROPERTY OR ADJOMNG gpf9FrY, <br /> i <br /> ry ..i. <br /> i <br /> ..: <br /> •i. <br /> i <br /> '. ... d <br /> : <br /> :. .. . ... i : ...... <br /> EARN g 2199? <br /> ?.... .. .: 1 <br /> SAN JO QUINCC'-JNTY� ;.. . <br /> Pl7BL1C HEALTH SERVICES <br /> �-NV[RQNlMZ <br /> DNNITBMM DIN ONLY <br /> ck—MsRwr>ti — --D.. F._....P..I�•T —OM.�7 <br /> O.wnwR.n I..P.;R.n eY <br /> ACCOUIRIIOOFII F: AB70 FACT <br /> rt COb11 FEE INFO AMORBYS RED C710C <br /> UNT ASN RBCOVeO BY DATE P911A17186RNCE RFT1U[1T N1 MSM INVOK:f <br /> 00 I / <br /> Pub.H/aMI Serv.-ErwvD.t73(3/96) <br />