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Lr APPLICATION FOR WELLtPUMP PERtat r _ y <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � ' ��� -_ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WESER AVENUE, STOCI(TON, CA 95202 JAN 1 X995 <br /> (209) 468-.3420 <br /> j., NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p :I <br /> ;I (COMPIMB M Trb6nEll <br /> d AP MAIMN 19 HERE BY MADE TO THE SAN JOAOUIN MtRiTY FOR A PEiWR TO CONSTRUCT MAgR METAL THE YAH(OESC USEO.THIS AWI.ICATMIN IB MAOf M COHIMIANCE WWII SAN <br /> IOADUIN COUNTY OEVEIORAENT TITIE.CHAPTER 9-111/1[[5.3 AAR,THE STANNO,AAOS/OAF)BAN AAWIN COUNTY)MMM HEALTH 9ERVKFB.ENNPONMEMK HEALTH OMSION. _ <br /> i1 NOB A00PE99AR ARlf %���� <br /> PAACM BIZEJAP . z <br /> OWNER'S NAME SItiGI+ AMMEBE ZJ.�! /V. i,taV <br /> ' coNTRAcroa fG+i i/ �Jam% / is'DY//M(1d>� k ALn]aFBB��G�j .� it!/(:;/A> Y/�� t�r��07��HE•T�lyG7-/r°6 <br /> SUE CONTRACTOR AppFEWS l' UCr PHONE• ''. <br /> '. r,,"Or WE mr,B QNEW WELL ❑ rEPEAcvAo•r WELL Q MOraIOHNO WELL• Cl OTN <br /> Q � <br /> MGTTA�U,ATMN ❑ WELL SYSTEM REPAIR ❑ CAOBS{OHNER REPAM QPD <br /> VAR XTRACTION WETL r <br /> DYPE OF PVMR EJ <br /> ❑NwI..I N.P. DEFT"PUMP 9ET PT. MET WATER LEVET. O <br /> ❑ OUT-0FSERVOE WELL El BEOFNYi1CK'W M.' �(`Aj BOR SORNO <br /> . QOEBTRVCTMN: <br /> INTFNOED UEE TYPE Ef WFly COMSTAUCT10M tPECIHCATTOXI <br /> ❑ INOUSTMAL QOPEN BOTTOM MA.Of WELL EXCAVAMN ,t,' q 0IA.OFCONfRRyORCA8PR, <br /> ClsA//4 OOMESTICNMVATE Q G11A1 PAOUMZE TYPE OF CAMHOIBTESIRA: /Y rT GIA.OF WELL CAANO O <br /> ,{E Ij-� O <br /> Q RM(BCMUMICMAL '6F"m, DfPtN Of GROUT SEK SPECIRCATpN n 1 R <br /> I ❑ 'FROATIONIAO QOT1E11 GROUT SEAL INBTY BY /�. GROUT BRAND NAME A / E <br /> MONROHNO GROUT eFKUM <br /> FFFD:❑Y— 9r . CONCIETE PFDEBTK w ormusTEQYM ❑IIs S <br /> II <br /> j} 7 /I. APPROX.DEPTH '//- .0 LOCXNO CHESTER ?J . <br /> 0� s <br /> PROAtm COMBTPUCTONIDFMIBIp METWD: MUD ROTARY AM FOTARY RUDER CABLE <br /> _OTHER�� . <br /> I I HEREBY CERTIFY THAT I HAVE PREPARED TMB APRJCATION ANC)THAT THE WOPK Vtlll BE PONE M ArO1IOAMCE WITH SIN JOAOUM COUNTY OHTNANCEB.STATE LAWS.AM RIILE9 AMO <br /> AEOMATONS OF THE SAN"AMON COUNTY, NOME OWNER OR UCENBEEO <br /> D AOENT'B NATUPE CSS6EB THE MUO,,R O:9 GENTRY THAT M THE FERMM AANCE OF THE WORK MR WHOM <br /> j. ]FE FOLLOW <br /> TME THE <br /> IS ING:MBUED.18NAt1 NOT EBEROY PERSON MMJECT TO WOI Ws COMPBIBATMM LAWS OF CAI/OIMA.' CONTRACTOR'.HM"O OR SUB-CDNTA ?Wl BMNATURE CEFOTFIEB <br /> ''1 CFiRKY TIUT M THE PEPFOMAM OF THE WOq(fOfl WMICII THy pDSU{M ISSIIfp.1 SNNL EL{[OY fERSONB SUBJ[CT TO WOMOPAIPS COMIBISAIIpM LAWS OF <br /> CXIIFOWA✓ Y/JFCUJC MIIKJ/p{L 2 AWIINOa ma ALL IBOIPREO7Ml&NPCET�M)X*AST IAM/s�IO�.S�iy2i�COMHETE.ORR RHO AT IOWg1 A Pao 0[O. <br /> ROT RAM mwM T. <br /> 1. NAMEB OF STIEETS OR NOAO*NEAREST T\UN INNS THE ROPEITI. l- LOCATION OF(MUSE SEWAGE DISPOBK SYSTEM OR NIOIORD <br /> 2. OUSINE OF THE PMPERTY.OMBq gMENMONB AMD NORSE OMOTION. - EXPANSION OF O%HR EE DIMV OR SYSTEMS. <br /> 2. OMENBONED OUTUNEB AND LOCRTON OF ALL"ROINO AMD PROPOSED R IDCATItM OP W'EWA WRTIIN LGA WOf ONE N1/NdEO fR'IY iT. .. <br /> SrF%X VIER.NCLUOINO COVERED NEL*M1CN All PATIOS.UMVEWAYB,AND WMX.. ON THE PROPERTY OR ADJOMIIM PFgOpRY'. <br /> Ir <br /> 3 <br /> I <br /> A <br /> mwry v lr INE w,t.r Q <br /> —.o/ ZJ <br /> R.astl.n� <br /> , Da. <br /> Dn. <br /> i <br /> '' I ACCOUNTEIO OMIY: NOf <br /> FAG <br /> FE CDOU FEE INFO KfgL�11NdT RtE1*TTED p By OATS <br /> OA/ ` - O I ` �THFANCE AEOUEiT MMBE# INVOICE ' <br /> or Li , c/F <br /> y PUb 'JBBHN Ser E^Nm 171 1.mr. - .- <br />