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� APPLICATION FOR WELLIPUMP PERMITAS <br /> AN JOADUIN C61pK•.-Y KIBLIC HEALTH SERIM. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, SMCXMN, CA 95201388 ORIGINAL(209) 4863420 <br /> MON-REFUNDABLE PERMIT <br /> APPLICATION IS HEM BY MADE TO THE SAN JOAOVIN COUNTY FOR A PERMIT TO CON ) THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMI'U WITH <br /> JOAQUIN COUNTY DEVELOM1kNT TITLE.CHAPTER$-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVIQDH, <br /> JOS ADDRESOMR AMM 23569 South Santa Fe RoadCITYRiverbank, CA PARcELIrzEAAMHI <br /> OWNER•SNAME Durhim Saleh Ali AODRIEBB Riverbank, CA 95367 209-863-923 <br /> PHONE. <br /> ARROWHEAD CONSULTANTS INC. 5/4-0851corrrRAcloR � AooREas Modesto, CA LRC1 P1N)HE <br /> am CONTRACTOR Pierson Drilling ADaa$$ Petaluma, CA 66-11 707-77T-7779 <br /> IID$ A,a INE <br /> TYPE OF WFLARJMP ❑ NEW WELL ❑ VlEll 13 OMNO WELL 1 ❑ OTHER <br /> ❑ MSTAUATION ❑ � MREPAM ❑ CRoe ONNEcT REPAM ❑ VAPOR EXTRACTION WELLI <br /> ❑N.w❑N.P.E H.P. <br /> RYPE OF PVMPI DEPTH PUMP SET—FT. HRST WATER LEVEL <br /> ❑ OUT,D"ERVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ BOIL BORMO <br /> ❑DfBTIlUCT1p N . <br /> IMTFNOED Ulf TYPE OF WELL CONSTRUCTION SPECWCATIONS <br /> ❑ MWSTNA ❑OPEN WTTOM DIA.OF WELL EXCAVATION DI&OF CONDUCTOR CASINO <br /> ❑ DOMESMPPRIVATE ❑GRAVEL PACKBQE TYPE OF CASNO/STEELJ V LRA OF WELL CABNNO 21l <br /> 0RIBl1C/MUNICIPAL ❑DPNEN 00"IOPP UT SEAL '7p�I �� SPECIFICATION <br /> ❑ IRPoOATgN/AO ❑OTHER GROUT <br /> VIP rS' Drilling ORpIIT BRAND NAME <br /> ❑ MOMrOMNG OROUT SEAL P CONCRETE PEDESTAL RY M"k❑V- ❑Ne <br /> AMROX.DEPTH 40' LOCKING VE PIP[ <br /> PROPOSED CONSTRLICRON/ UJ*O METHOD: MUD ROTARY AIR ROTARY ER CABLE OTHER <br /> I HEREBY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WOW,WILL BE DONE M ACCORDANCE WITH SAN JOAWN COUNTY DFDMAHCES, STATE LAWS, AND RULES A <br /> REOULATIONS OF THE SAN JOAOUM COUNTY. NOME OWNER OR LICENSED GENTS WONATVRE CERTIFIES THE FOU DWINO; T CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WM <br /> THIS PERMITIS ISSUED,I SHALL NOT EMPLOY PERSONS WILIECTTO WOROAAN•B COMP011ATON LAVAS OF CALFOFM ' CONTAACTOR'B NBENO DR SVR{OMTRACT/N0 6ONATVIF CERTO <br /> THE FOILOWINO; 1 CERTIFY THAT INE PEYORAIANCE OF THE WORK FOR WHICH P FEl1V SMR IB ISSUED.1 SMALL EMPLOY PERSONS SURJECT TO WOROMAN•s COMPKXSATION LAWS <br /> CAUFOP111A.' }11E,AP &NT MU1T ALL M NOW L,RE M ADVANCE FOR ALIN IN AT ASMI1BLl4v, COMq,ETE DMWMO AT RAWER AREA FRONDED. <br /> Sb M X44u, <br /> D.,, 07-22-98 <br /> HUT PLAN PLAN,o Ba�Slg <br /> 1. NAMES OF cTHEETe FE ROADS NEAREST TO OR AND <br /> NOR THE PROPERTY 4. LOCATION OF HOUSE SEWAOE N1 SAL SYSTEM OR PROPOSED <br /> 2. OUTLINEMSI Of THE PROMRT N LOCA IONDIMor ALL AND NORTH DIRECTION, EXPANSON OF SEWAGE DISPOSAL SYSTEMS. <br /> 1. DIMENSIONED OVTIMF.6 AND LOCATION OF ALL EXlSI1NG AND PPOPOSEO s LOCATIONOF WELLS V N RADIUS OF ONE HUND,,,,FIFTY <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS, VEWAYS.AND WALKS. ✓�/�/"- 'T OR ADJOIMNO PROPEIITY. <br /> DRN <br /> I <br /> ° .. <br /> ...... MAP ON BACK ,p sly. <br /> OEPAlTTMpfT USE ONLY <br /> ENVI E EALTH O <br /> APdlrl{M Aeo.Pl.a By <br /> Nr� <br /> Grw l:wPr, By <br /> P,R„p h� W I, <br /> Urlrvctbn IrwP.al By r <br /> Lumm.M.: mrk�.0 7xif/a <br /> 0 P <br /> ACCOlMRNO ONLY: AI01 FAC1 <br /> PE CODU FET INFO ANOINT R8.IRTED CHWUMAM RECENED BY DATE FF)P,tR/IfAVICE REOUEST NUMABI INVOICE <br />