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APPLICATION FOR WELIJPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 9SZb2. <br /> 304 EAST WEBER AVENUE. ST•OCKTOK CA� <br /> ----- - <br /> -1-1209).""00 <br /> BION-REFUNDADLE PERMIT <br /> ORIGLNAL ; <br /> ' <br /> AITUCATMN S HERE BY MADE TO THE SAN JOAOUIIN COUNTY FOR A PENSfT TO CONsTmic-T ANO/IIR INSTALL THE WORK DEs romm-'T1SS APPL1CATlON K MADE IN COMPLIANCE WITH SAN <br /> JGAOUW COUNTY DEVEl1Dpumr TITLE•CI1Arm*-1115.3 AND THE STANDARDS OF SAN JOAOUIII COUNTY KWJC HEALTH SERVICES.SI M IONMENTAL HEALTH DMOON. <br /> JOB ADOPEBBUDR AFNI `414N% (�\\E• crrY �,A��O�P PARCEL.QE►APNP <br /> owNENRy NAME �(OSCO �P0.`�•EZ�NG CAMQRN`l AIEBS1000 OQOW C ' �fk"'AQ`•��`1001SAN Q\C�4N CF w g3 `its <br /> DDZ�1-t33$ <br /> E ZNC. ADOWSS p2`� E. CNA0.�60.Vl ua 3'1 S(u0 PHHONE o Yet bl6 <br /> CONTRACTOI <br /> PUS eoNTRAR:TDR _ AOOREss S OCY�IJN ucf PHONE s <br /> TYPE OP wnLnyMn ❑ NEW WELL D HEPLAcmw WELL ❑ Mow"ww o WELL. D a"" <br /> ❑ INSTALLATION ❑ WELL srsTEAH REPAST D CROSSCONNECT REPAIR D VAPOR On RACTI-N WELL• ✓ <br /> O N..rO%w* H.►. DEPT"PUMPSET FT. POW.WATER LEVEL C <br /> TYPE OF PUMM <br /> OVT•OF-tERVCE WELL ❑ OEOPHYIICAL WEtl./ ❑ SOL so moo <br /> �� �Y pFSLFo(tE1t�NC� ANp QciESS00.E G(Lao: \H�, E��s���at, \9E1J_ C�s�NC� \N Ql1�c � SSE �'nAtNEO W00.�Q�N <br /> p/Dm Wt TYPE OF Will CONSTRUCTION SPgfICATIOM A <br /> ❑ INousTwAL ❑OPEN BOTTOM blk OF WILL EJCCAVATMN DIA.OF CONDUCTOR CASING D <br /> O OOMEETICIPMATE ❑GRAVHs.PACKfSQE TYPE OF CAMNDMTffi1PVC ORA.OF WELL CASING D <br /> O puwxMUMc r& D bwim DEPTH OF WOW SEAL tPEC1FlCATKIN R <br /> O AGDAIMNIAO ❑OTHER ORDUT SEAL INSTALLED BY O/IDUT BRAND NAME E <br /> ❑ UDNTTomm WOW STEAL PUMPED: ❑Y. ❑N. CONCRETE PEDESTAL K DwLLER O Y.. ❑N. S <br /> APPROY-bVTN LOCKING CHESTER DOXISI VE PIPE s <br /> MROPOGm OOIMf11UCT1oKMFAUM METHOD. MW ROTARY AIR ROTARY AUGMI CABLE OTHER <br /> 1 HERESY Can.WV THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WO/K WILL BE 0044E M ACCORDANCE WITH SAN JOAO"COUNTY OMMIANCES,RATE LAWS.AND RULES AND <br /> PEOULA,TIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR IJCENSED AGE M SIGNATURE CERTMVES THE PCLLOWINO:1 CERTIFY THAT IN THE►EIIPORMANCE OF THE WORK FOR WHICH <br /> THIS PERMrr M ISSUED.1 SHALL NOT EMPLOY PERSONS TO S COMP9HSAT aN LAWS OF C/WFOwM&, CONTRACM"HMSNG OR SPT-CONTRACTING SIGNATURE CERTIFIES <br /> TIRE POLLDWMM C T E THE POR WINCH T1MS K ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WINRKMAN'S Com"N j10N LAWS T <br /> �pwSA,• M 11SOIllllm AT�4SS.it'l1 MPLETE 011AWIN0 AT RAWER AREA dt <br /> X Tlr. O.t. l/ <br /> PLOT PLAN M40w r S..W Srl. '1. <br /> f. NAMEs OF SR PI <br /> 'T'REETS ODADS NEAREST TO OR sOUIM)ING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSALwm O ►-SED <br /> 2. OUTLINE OF tW MHOPERTY,OWMM OMRIEMSIONS ANO NORTH MWCTIOk. EXPANSION OF•EWAOE-1M"OSAL SYSTEMS. <br /> 3. OIMMsIONEO OUTLINES AND LOCATION OF ALL E70CTPM AND PROPOSED S. LOCATION OF WELLS WITHIN RAM$OF ONE 04UND4ED FIFTY FT. <br /> STw1CTUIES.MHCLUOING COVETED AVIS"SUCH Ai OATIO8.ORVEWAYS.AM WALK& ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ..........�.. .. ...j..� ...<....... �� ...... <br /> •...i:.._`...N... ..j.............K.....-`.w......_.......�...... .....i....._ .. .. . <br /> ..i... «_••_.y... ...0.....S.. .._. ..I ..C......... .. <br /> ..j- �......�..... .. .......... <br /> . .. ....... .. <br /> :..._._.... BACK ..:... <br /> : , <br /> MAPON...... ...... ...... <br /> s.... . <br /> . <br /> ............ <br /> .......................... <br /> DBARTMIw USE ONLY O.I. Ar..O <br /> I <br /> APs..Hlm A...rl.!BY, <br /> Onut kw.ell.11 BT Kno wf...M.O B1 DN. <br /> ACCOUNTING ONLY: MDI FACT <br /> PE CODES m P" AMOUNT Rejarl"m CHEMIC"N hECENED SY DATE ►E1114TIS6RVICE I"Um NUMS01 INVOICE <br /> p -0- --'A^ Awn IF Ij? <br /> www • <br />