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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 952002 <br /> (209)468-3420 <br /> !OR-0frUNDABLE PERMIT EXPIRES 1 YEAH FROM DATE ISSUED <br /> ICempM11 In TltplkRl►I <br /> AMICA710N 19 OPTIC RV MADE 70 711E BAN JOAOUIN COUNTY Fon A PERMIT TO CONSTRUCT ANwon INSTALL THE W0W DECCPoRED.71"S APPUCATION IS MADE IN COMPLIANCE WTTN SAN <br /> JOAGUPI COUNTY DEVELOPMENT TITLE,CNAPTER 9-1115.3 AND TIIE STANDARDS OF B/AN JOACUIN COUNTY PUBLIC IIEAL711 SERVICER,ENNEgNMENTAL HEALTH DIVISION. <br /> JOB An""FNIVOP ArWI 1�/. [[J, I {{/i c.�`I7r/��1/� '4(,1 C-IITY(�_> //Q c� �/ I PARCEL <br /> /SIZE/APHI Z5D-29D"0 I I� <br /> oWN/t"'SN ME WCSlerl QLrci4e'"12�N 4 LSId Y4Ybfl. AnbRE9R.L e& CC) ��Iq Fa AJ hyG mfow#75y S6y 112 <br /> ON1}UCFOR Anlp/ Iiean, C-eO/OSlc9/ -Se�ulceS AOIXIER9/�Oy2 M317DnWn�1_"Co�i$_�n/DNEF_531-802/ <br /> vmcoirr Mclon_ V )� }1f �riI^1 AODniae �I1 J4<-J� KID FjI4 LOCI CS 7-7/067!1'IroNE1�7 <br /> TYft OF WELVMMP: ❑NEW WELL ❑PEPEACEMENT WELL ❑MONITORINO WELL/ Q OTI/ER <br /> ❑INSTALLATION ❑WELL RYSTEM"[PAIR ❑CnOR9-CONNECT REPAIR ❑VAPOR EXinACT10N WELL I ,/ <br /> _ ❑Naw OM-1, M.P. bErI11 PUMP SET_FT. IInaT WATER LEVEL O <br /> D VI`E OF P/MPI —' <br /> ��1 (3our-Or-BFRVICF.WEU 11 nEOPNYI-SfCALLF-7,WELL I LJ Roll momma <br /> MEPT <br /> O111/CTION: NI I <br /> `h l ., we#.S <br /> IN I ENDED USE Type OF.WELL CONSTRUCTION SPECIFICATION A <br /> 11 INDUS7MAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONOI/CTO"CASINO O <br /> F11 MMEPIIC/FaIVATE 1F-17 OnAVF.I PACKID17E TYPE.OF CARINOf97 EFL/PVC MA.OF WELL CASINO O <br /> lJ"Ia1M-BJUNIC. 'AL 0nN1VFN "FPII OF nnOU1 SEAL 9rECIrICATION R <br /> ❑IMIOATION/AO ❑OTIIEn Priam SEAL INSTALLED BY GROW RRAND NAME E <br /> Cl MONITOnINa O110UT SEAL PUMPED:11 Y- ❑Nn CONCRETEPEOESTALNVORNLE":OY. CIN* S <br /> Ar/KOX,DFPTII LOCKWO CIIEef En ROX/910VE PI'F. J <br /> PPOI'ORIn CONITAUCTIONfOR LUNG M"NOO:MUD ROTARY AIR nOIAM AUGEn CAME 01"Fit <br /> I IIERFRY CENT IFV IINAT I NAVE I VIEPAIIED 114I6 APPLICATION AND INAT INE WOIK WILL PE DONE IN ACCORDANCE WITH RAN JOAOVIN COUNTY 0"Of"ANCER.RT ATE LAWS.AND PULER AND <br /> nFOULATIONR OF TIIE BAN JOAOUN COUNTY,HOME OWNEn On UCENSEO AOCMT'S RIONATURE CERTIFIER TME FOLLOWING:'I CERTIFY THAT IN TME PE"rOW/ANCE or TIIE V40M Fon WINCII <br /> TIIIF 1`FRMIT I9199VE0,1 RIIAI l NOT EMrtOY PERSONS SUBJECT 7D WORKMAN'S COMKNIANON UWS Oi CAInONRA.'CONTRACTOn'S IUMNG OR RVR-CONTRACTNLO SIONATURE CERTM'IEI <br /> "It rOLLOWINO: '1 CERTKV THAT N TIIE PERFORMANCE OF 711E WOIK TOR WIIICN TIIB TI MIT IR ISSUED,1 911ALL EMPLOY PERSONP PURJECT TO WORWAAN'S COMPENSATION LAWR OF <br /> CAIJTOIINIA.' T /I'UCANiAMVRi�JCALL 4"OUR$IN ADVANCE FOR ALL REOVNFO 1114"CNONS AT 12"14Hi1 11,COMPtIl OMWINO AT LOWS"AREA MDVDED. <br /> Jrd'' ,1 e �1 L-p <br /> ele.,.q x_ i.l, 1/ TTI.Cfe'Yk zT, Arte! rq-A <br /> ROT FUN"N-IS 8.0.1 Se.M 'In <br /> 1.14AME9 OF 9t REETS OR IIOADI NFA/1E9T 10 O"aO111"'W"711E FTDrERTY. 4,LOCATION Of IIOUBE IFWAGE DISPOSAL SYRfFM OR PfDiR)9Eb <br /> 7. <br /> at"tip*OF 711E PfIOR"TY,OMNG DIMENSIONS AND NORTH DIRECTION. EXPANSION Or IEWAOE UORPOM BYBTF.MI. <br /> 7.DIMPNRIONEO OUTIINtS AND LOCATION OF ALL EXIRTINO AND PaOrORF.O S.LOCATION OF WELLS YNTIRN RADIUS Or ONE IDNnntn tNIY Ft. <br /> STRUCTUIIES,NCLUDINO COWLED AREAB SUCH AS PA1D8,DW VEWAYS,AND WALK#. ON 111E Pnop[nTY On ADJOINING PBOPE"tY. <br /> dee_ N�1ce�l' SI tC /¢n <br /> OE"ARTMINT VSE ONLY <br /> Arnae.Ilnn AeorolM R7_ !' ` /7t�T'�-�9�T� 1/`'�/ b.11'17�_A- <br /> 0-4 ImFnnNlnn 9, D.I. P v IrMplellnn BT OH <br /> fACCOLNIINO ONLY: � AW —� rACI 1 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKI/CAIN RECEIVED SY DATE PBS1117120"ACE PEOUEST NUMBER INVOICE <br /> O01— O I <br /> Pub.Health Serv.-EnAro.173(1/97) <br />