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9-30-1996 12:08PM FROM P- 2 APPLICATION FOR WELIIPUMP PERmrI SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OIVISIOA P.O. BOX 38$ 304 EAST WEBER AVENUE~ STOCKMK CA i�W (209) 4624420 �„ /�lCn , MON•REFUMBLE PERMIT EXPIRES 1 YEAR FROM Ok�E'9-SU-% j� � / T� Xmp(sb in TrlpGwul AP''UCATMU 16 HERE BY MADE TG THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL TTiE WOPR DESCRIBED.THI DES APPLICATION W LADE M COMPLIANCE WTrH a JOAQUIN COUNTY VEMLoPea TTfLE,CHAPTER 9-1115-3 AND T...H..��E//STANDARDS OF 8AN JOAOUIN COUNTY PUBLIC HEALTH SERACE9.ENVIRONMENTAL HEALTH DIVIBION- JOB ADORESBIOR APNO /Wes LI Gy ST- F A1,T4 T CrrY S7IG1(/,- EL 84EJAPNI � ` t PARC �{* cles OWNER'S NAME (f: 7,—c- 1 ADDRESS Civ //�+//qZ�C(1 �i,5EZ4-1— -,-N�i32- 8906 CONTRACTOR '��g�u.C`( f(�^��.Z�� AGGRESS S�7' + o-r—�� 5 U" SUBCONTRACTOR TYPE OF WELA^MP- ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITop#w WELL/ ❑ OTHER A/ /� ❑ INSTALLATION 11WELLaT'EM REP WESYAM ❑ Cms&cONNECT PEPAIIR ❑ VAPOR EXTRACT1oN WELL! /Y ? 13m..❑Rgdr H.P. DEPTH PUMP SET FT. FIRST WATER LEVn RVPE OF PUMP) c ❑ OUT.OA-w"CE WCLL ❑ OEOpPHYMCAL WELL• ,�9o1L BpRiNG �d ❑DESTRUCTION: �.� 3u1,45 T" gr��•f ('✓��•.( . INTENDED USE TYPE Of WELL CGNSTR OM SPECIFICATIONS ❑ MDU3TRIAL ❑OPEN BOTTOM DIA_OF t!�F.LCAVATTON -'^ 4 OLA.OF CONOUCTOR CASING ❑ DoMEBTKIRBVATE ❑GRAVEL PAcuuaE TYPE OF cAs*xL/Qrcm vvC / DA.OF WELL CASINO ❑ PUBUCIMUNICIPAL ❑URVEN DEPTH Of GROUT SEK - i:--Z( �� 4 WECWICATTON �❑ XW&aAT10M/A0 ❑OTHER OROVT SE/1L M46TAum BY OAOUT 3RAND NAM yE LYI MONIYOF0N0 ! SG MP/,ma) WNDUT SEAL PUMPED: ❑Y. []Me CONCRETE PEDESTAL BV OF*jj;t.❑Y. ❑N. APPROX.DIiPTH T— Lomm CH 81m 9oxmrovE RPE PROPOSED CONSTRUCTONIOM I WO METHOD: MUD ROTARY AIR ROTARY ALHA—lZ—CABLE OTHER I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLKATbN AND THAT THE WORK WILL Be DONE M ACCORDANCE VATH SAN ;DAQAW COUMTY oROrNANCEB.RAT!LAWS.AND RULES M REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR UCENBED AQENrS SIGNATURE CFS THE FOLLOWMQ:'R CERTIFY THAT IN TWE POWORMANCE OF THE WORK FOR%o*w TMS PERMrT IB ISSUED,I SHALL NOT EMPLOY Pp4BoNB SUBJECT TO WGRIWAWS COMIlet"TION LAWS OF CAUFORNA.' CONTRACToR9"*GP/O OR SU6CONTRACITNG SIGNATURE C£RTm, THE FOLLOWING; 'I CERTIPY THAT W TK PERFORMANCE OF THE WOsK FOR WMCH TNN PEPMWr W 168UED.1 SHALL EMPLOY PER®ONB SUBJECT TO WORXMAMS CoMPVtiATION LAWS t CAUPOIW&- Tb@g M CALL 2S 140tM a Al VAMCI POR ALL RECURRED 0"WWTIONS AT 1209)440-2422. COMPLETE ORAW..G AT LOWER AREA PROM 9Wn.d x I ull f< T.. �Smc� �? Ste+ PLOT PLAN(D.....to 96.1.1 9..1. -to I. NAMES OF STREETS OR ROAOS NEAREST TO OR BOUNOINO THE PROPERTY. A- LOCATION OF HO 9"AGE OISPOBAL SYSTEM OR PROPOSED 2. OUTUNF Of THE PWPERTY•OPANG DNUENSTONS AND NORTH DWCTUW- EXPAIMON Of SEWAGE DISPOSAL SYvT0d% 3. DUAENi10NED OLTTUNF.S AND LOCATION OF ALL EXISTING AND PONOMSEO S. LOCATION OF WELLS wTTUM RAORJS OR ONE HUNDRED FKTY PT. STRUCTURES.INCLtMNO COVERED AAEAB SUCH AS PATH.DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING RIOPERTY. ....... ........: .. .I ...........i.....i ....j... v ..... ......>......V.. .. .. ...i............... .. ....... ..........i..... ... .. .. :>. ,":..I. ....1. ....... >.. :...... t.. t ..... .�.. ...... . .1 .!•....i... .. ..p...........•.. . ... .. .. .. ......... ... .. _... .. .. ...j .. ..............w... .. . ............ ..... .. ........ ..n... . .. j .. .. ...�... ....... .. ....... ....�. .. t ...l.... ...t.. .. ....s.... ...i.... ...... ...y... ...5... ..j .. .... . ..I ..t.. .._.. . . ..t. ... .....e....:.. . .. .. .. ........ ..n.,•...t ...e ...i... ..p............. . .. oaA*TMEaIr USE ONLY PW t a., to- Ap1l6.Il.n Am.Pt.d BY 3r.ut D.t. Puna•II>♦vatHrl Br Owe ow'wd—Iti...Ibn BY E C61ntn.ntr ACCOUNTI NJ ONLY. AIDI FACV .{ Pf coo" In Owe AMOUNT REMITTED CHe=WJCASN PmgvrD By DATE P99b11TlsumcE RMUCST mumeet INVOICE