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APPLICATION FOR WELLIPUMP PERMIT <br /> ,'SAH JOAQUIN COUNTY PUBLIC HEALTH SERYPrA! ' <br /> ENVIRONMENTAL HEALTH DIVISION . <br /> P.O.BOX 388,304 EAST WEBER AVENUE.STOCKTOK CA 95201388 <br /> 12091461-3420 <br /> NON-NEFUNOANLE PENULT WINES 1 TEAR FROM DATE ISSUED <br /> fGIRPI[4 M TrlpM*b1 <br /> APPLICATION M NEVA 6Y MADE TO THE SAN JOAOVIN COUNTY FOR A PEM"TO CONSTRUCT ANUMM INSTALL THE WORC DESCRIBED.TMS APPLICATION IS MADE in COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITtE,CHAPTER 9.1 116.3 AND THE BTANDAADS OF SAN JOAOUN COUNTY Fj7 HEALTH SERVICES.ENVIRONMENTAL HEALTH CrAlpoN. <br /> JOB ADDRESSOR APNI ?Sn %' �1'�rr1i F 111n, -q-n �`•t^ PARC r,�'•. -I-a <br /> � CRY I PARCEL eREIAPNF wr r <br /> OWNER'S NAME r'1' " v 1�r �� ADDRESS f�v 'I N 'I-%,P gpNE <br /> COMTRACTON'• T V Nl Irt �-• A 4 n nr UJ'I T�„ _ " til I <br /> AOOREBS r.. 'f I� '�nf.I "ZI�L,-lnl- <br /> LK:F, X17 PHONE F <br /> epe coNrRAcrpR�I 4 r r V L f nf1 1'ti F R F Iw• w. I 4 E. P ry s '/ <br /> t' ADORESS',)L I P�15 L I�nJle S S P�LICF_L_T..Y <br /> TYPE OF w[LuwMP ❑NEW WELL 13 13I-.-1I REPLACEMENT WELL ❑-I MONITORING WE"/ ❑OTHER <br /> 1 <br /> ❑NOTALLATION WELL BVSTEM REPAIR ❑CROt6COMMECT FEPAPR ❑VAPOR EXTIUICTION WELL F J <br /> ' Q N—13A�.A N.P. DEPTH PUMP SET FT. FPABT WATER LEVET. o <br /> RYft OF P{R�I � ' <br /> _ C'l OUT-OP-SERVICE WELL ❑OEDPMraCµWELL F IJ tO0.NORND B , <br /> 1 ❑OESTRtICTroN: I <br /> NTENOW Ut[ TYPE OF Wal CONSTRUCTION fPEtIFICATIONi A <br /> ❑NOUSTRAL ❑OPEN aorroM DIA.OF WELL EXCAVATION GIA.OF CONOUCTOR CA&NO p <br /> ❑DOMERTICRLLIVATE ❑GRAVEL PACJ(MZE TYPE OF CASNONTEEUPYC DIA.OF WELL CA&ND O <br /> ❑PUSUC&UNCIVAL ❑DRIVEN DEPTH OF GROUT DEAL SPECNICATION R <br /> ❑mPXj ATNpNIAO ❑OTHER GROUT TEAL NerAL"D STBR <br /> Y GEIour AND NAME <br /> R ❑ [ <br /> E, ❑MONToNO GROUT SEAL PUMPED: V- ❑N. CONCRETE PTOESTAL SY DWLL[A:❑V- ❑N. t <br /> APPROX.DEPTH COCK**cHEerEPI BOX76row PR{ <br /> PROFOSSD CORSTRUCTPDNMWLLJXQ MRHOD: MUD NOTARY AIR ROTARY AUGER {' CABLE OTHER U �A <br /> I HERESY CERTIFY THAT 1 NAVE PREPARED THIS APPLICATION AND THAT THE Y4OIK WILL BE GONE IN ACCORDANCE WITH RAN JOAOUM COUNTY ORDIMEB. A <br /> A <br /> REGULATIONS OF THE BAN JOAaUIN COUNTY.HOME OWNER OR LICENSED AOFNT'S SONATUPE IFY CERTIFIES THE FOLLOWING:T CERTTHAT M ANCDT TE LAWS,AND RULES No <br /> THE PR'.TipRPI VT Of THE NRR(EOR WHICH <br /> L <br /> THIS PERMIT IS M91 ED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORMAN'S COMPENBATION LAWR OF CAUFORMA.'COMTRACTOR'B NRNO OR SU&COMTAACTr O WNATUN T C[RTGIF <br /> THE FOLLOWING: '1 CERTIFY THAT IN T44 TPENIFpPIMANC[OF THE WORE POR WMICM THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SVI IECT TO WORIWAN't COMPRISATIOIE LAWS OF <br /> CAUFORNA.' THE AFIYlc MIXT CALL 24 NOW IN ADVANCE FOR ALL RTOLM ID IMSFECTgMt AT\ISM1 -S'I2f,(COMPLETE ORA-NO AT LOWER AREA PIONDED. <br /> 1 AF„1L1 ft�•\`s lT <br /> ! Dlgnrd X t TM. •� ^, 0— I <br /> ' FLAT FUR 0—I.S..I.I te.l. _ •I. <br /> rOr- I 'I 1.NAMED of"It"*OR ROADS NFARFEr TO OR BOUNDING THE PROPEIRY. 4, LOCATION OF HOUSE BEWAOE(MMOSAL eYSTEM OR PPOFOSEO <br /> 2.GVTLIME OF THF FRGPEIrtreMNO DIMENMNS AND NORTH DIEIECTION. EXPANSION OF SEWAGE DISPOSAL RYBTEMO. <br />+ O.DIMENMWO OVTLNIFS AND LOCATION OF ALL EXISTING AND PRDPOS[D S,LOCATION OF WELLS WRNMI RAMS OF ONE HUNDMO TFTY FT. <br /> 3 STRUCTURES,INCLUDING COVERED AREAB SUCH AB PATIOS.ORVEWWAYB,AND WALLAS. ON THE PROPERTY OR AD"INM PROPERTY. <br /> F <br /> - '-.-. ... ... <br /> . <br /> I <br /> m i <br /> I m <br /> ............... <br /> ... .. .. . ... ..... - <br /> € i <br /> 0.e. b.. <br /> O.qur 4wPemlen Br l OH. PvnP Ir.o�aPr,er _ p4l• <br /> prinsrl.n InNe,atlsr Br �. ... <br /> �7ACcGUNnna aNLrI AIOF PACE <br /> IPE toDG FEE INTO AMOUNT REMITTED CHECKRICASO RECERTO BY DATE PETSAITMERVN.E AEGUEST NISHBRI IRVOM:E <br /> I <br /> l <br />