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IJAPPLICATION FOR WELLIPUMP PERMI j <br /> SAN•JOAOUIN COUNTY PUBLIC HEALTH SEI49 r <br /> J I ENVIRONMENTAL HEALTH EUVISION I <br /> P.o.`e6X <br /> 38%304 EAST WEBER AVENUE,STOCKTON,C J.M it <br /> ii 120914883420 <br /> It <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> II ICOMPIBN In TFIPRCBN) <br /> APRICAF ON IB HEIS W MADE TO THE SAN"AWIN CWNFY FOR A PERMIT TO CONSTRUCT AN DOR INETML THE Wb%L OEBCWBEO.THIS APPLICATION IR MARE IN COMPLIANCE WIIN RAH <br /> MAOUIN COVNFY DEVELOPMENT CALS.CHAPTER 9-1111.3 AND THE STANDARD.OF SAN bA0U1N COVNry FUNK HEAL"REAMES.F,,,w ,CAt HEAT"MMMN. <br /> Me AOONe@bR ARMS ys 44sr llfk ;A G/.B✓ CITY�I ,Sn4en',✓ PRISCO.6WAwM <br />�. OVMER'B NAME /. <br /> ADDRESS O. COL/_GJ% GAJrB <br /> CoTMCTOn CsLnYrL<-2✓ALJ Sni+ i AWNscdK✓6aDG«IeA1P 0 eQmr PEn Y/7 PLIONEr�.Y)L1/�A,7[B <br /> EUR CONTRACTOR &0, def:4 AODR[RR St Lir moNE <br /> A <br /> TYPEOFMLlA41MP ❑NEW WELL ❑NPIAC[MEM WILL ❑MOMTO%HO WELLI ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑ORRRRLONHECT @EPA.. ❑VAPOR EXTMCTIONMIA.1 i 1 <br /> DYR-OFMMM <br /> ❑NWIOAtnt* HP. ., OEM,PUMP OFI�FT. FIRSTWATERLEVEL O <br /> � <br /> 13OUPOF-IRIME WELL 1 ❑OFORIYSRA WELL r ❑ Ott RdENO AT <br /> C <br /> OEE ���g,,�„a,..�.--._� aFt/,D�f-- .r >-/ tee. /aa z71,1if, <br /> IXTFMOFO VRTECREDEMIA. CONSIRUCI ON BPFEV CAI ONB A <br /> ❑INdIBTPoA ❑014N.O ROM ,1 DIA.OF YRLL EXCAVATRN DIA.OF CONDUCTOR CASINO <br /> D <br /> ❑WMEBEKRI.VATE 13 GRAM PAKAMCE TYPE OF CAFM.MTEELJPIC NA.OFWELLCAMHO O <br /> ❑RIRLMAEUMICNAL ❑10M. II DEPTH OF ORDLIT EFAL SPECIFICATION A <br /> ❑dWOAIMMIAO ❑OTHER SMUT REAL INSTALLED BY NbUT.MNO HAMS E <br /> ❑ANABOMNO it OAom BEA AIMAmr O Yr E]No CONCREVEIEDEBTANYORRISh OYME]Ns d <br /> ARROW.Som" LIFOO.CN[R[R NOXIRTOW RPE <br /> d <br /> RIOPERM CONSTIUCTOXIOWIUNO METHOD: MUD ROTARY AIN FILE. AMER CASTE OTHER <br /> 1 HERE"CERTIFY THAT I HAVE PREPARED TNM APPLICATION ANO THAT INE VANx WILL IN GONE IN ACCORDANCE MEN RAN MAp COUNTY ORDINANCES,STATE LAWS.Alb @VIE.AND <br /> PEOULATDNR OF THE RAN JOAONN COVMY.HOME CORNER OR IbENNO AGENT'S SMNATUN CtAAFIEB THE FOLLONtNO:'I CERFIFY THAT IN THE PENDMM E OF THE MBAS MR WHICH <br /> THIS PETAAT M IENEO,I MALL NOT EMROY PERSONS SUBJECT TO WORWAN'I COMPENSATION IAM OF CALROIRIA:COMMCTOWS MWHO On R OWRM.TMOe ATVIIE C[bSRB <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE NNOPMANCE Of THE WON FOR WHICH TWO NNArt It IBDND.1 SHALL EMPLOY PERSON@ NNIECT EO WdIRMARY COMPdM1HIN IAMB OF <br /> CALIFORNIA. THE APPLICANT MORE CALL N HOLAW IN AWANCE FOR AL MOMN RINSPECTORS AT DEMI 4011,2422,COMPLETE dNLNNG AT LOWER ANA RDNOEO. <br /> .ISM k / �/�A� �rP}W������ <br /> ROT MN brw to Raxx Sall. <br /> 1. NAMES OF ST NFO.OR ROADS NORMAL TO OR SOUND NO THE%OPEAFY, r.LOCATION OF HOUSE SEWAGE dWSA BORROW On P OPOSED <br /> 2.OUTLINE OF THE RDPERrv,dWNO DIMENSIONS AND FORTH DIRECTION, EXPANM H OF.PNAOE NNOML WATFMS. <br /> 2.DIMMRbNEO OUTUNF.R ANO LOCATION OF AL EXISTING ANO PROPOSED S. LOCATION OF WDLB WRIOH RAdV@ OF ONE HUNDRED IBM FT. <br /> "FLACTURFB,SIMMONS COVERED AREAS SUCH AS PATIO.,FM VEWAYS.AND WALXB, ON THE ROPFTY ON AOMIMNO ROPERry. <br /> i <br /> 1 jEznLc <br /> _ aRJE'lAWLA . <br /> _o. ......!. !°E <br /> DEPARTMENT USE ONLY <br /> AP.oH . f5 <br /> J'• 1� n.. . <br /> meM Ir.p.nlen er - RxP PImF IMPtnxr.r - Dx. <br /> Rsr.rRn..IlFol r RO DSt. <br /> C-1.: GOS If !aerm,Li (vq.M�Z <br /> a <br /> A.COIdn"O SNIT: AIRF FACE <br /> PE COD" FEE two ANOIdTTMITTEO CHECwbARN TOOVEO BY DATE NIVAITMFIIOCE REQUEST NUMBERS INVOICE <br /> 35u2 a o35F 5.9� BIZ <br /> .I <br /> s <br />