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APPLICATION FOR WELLIPUMP PERMIT <br /> • SAN JOAUUIN COUNTY PUBLIC HEALTH SERVICES. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 3K504 EAST WEBER AVENUE,STOCKTON,CPA <br /> 12091488-3420 RECEIVED <br /> MON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE13RUED NOV 15 long , <br /> Mompkl8 M TTIpIkMMI SAN J0,'1,!-N('LJ, np <br /> AMMATION IB HEN BY MADE TO THE$AN MAONN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL T IIE WOnL Of BCPoBFLQ(JeL/KPIYwMFVfL�1',i. 1FEIq ANCE MIT BAN <br /> JOAQUIN COUNTY DIEVILOMINT TITLE,CHAPTER B 1115.3 AND THE STANDARDS Of SAN JOApI1N U FURNIM HEALTH BFEJaVN70N1R4MF1WC1E LLFL.tLFH,jT�I.PRTII� <br /> 4Jla L+,(.3- 4MTf rsq�, 11 rl <br /> JDRAo6VFG=n/uN)fy CP0W11k�F1414DM7' �FN7NwR H.tR,NI733H0APOElary �IU(-A 10 ki 1 PARCEL SNNARN pL <br /> OwN[n'ENMI[J,L 4 [)I' SfacKToPI ACORF..Nn M_ 61. porlgdo //'',�(( n1oNeA93'7'AygS�S1S <br /> CONTMCTon IIQLyQ+ME<d Gee Eh Niroltmex ll ADDREBB11�[0y3 VKfiar i I-FI, S10gic,- "MINEIy%U"12/��L <br /> sus C.M"CTOR 5Oil 5 1FA p 10101.6 f Sa)10 RLI f 1q ADMISS�U11 $p (�r,INP111CjQucP x876 nwrN MY07'INS•,L 7Q <br /> TYPE OF WELLIPUMP ❑NEW WELL ❑REMCEMENT WELL IN MONITORING WELL 114 TO I ❑OTN[R <br /> ❑UVTAUATNIN 11 MIT SYSTEM REPAIR ❑CME.CONNECT REPAIR ❑VAPOR EXTRACTION WSiL1 J <br /> ❑TH-13Iwo, IV. DEPTH PUMPBET_FT, FIRST WATER LEVEL a <br /> um Of NMn <br /> ❑OUP OF SERVICE WELL ❑O1.14TY ICAL WILL f ❑ BU,..AP.O / <br /> ❑DESTRUCTION: <br /> INTENDED USX TylIt OF wm CONSTRUCTIONN U, O IF A <br /> ❑INDUSTRIAL 11 <br /> on"BOTTOM RA.OF WELL EXCAVATION DIA.Of CONDUCTOR CAIINO O <br /> ❑OOMEBT..VATE 19 CRAVEN MACKMIEE�� TYPE OFCABINO/BT[ILpJC Y1w C VIA.OF WfLL CASING �� D <br /> ❑ WBuc.,MCIPAL ❑.wH OHTN Of OMUT BEAT f+ SPECIRCATION R <br /> 1❑p NWOATKRUM ❑OTHER OMUT BFAI INSTALLED BY HLaT C+11fK1 GROWBMNO NAMEPo4 IN CBMIfRr E <br /> y{MONNONNO J� � OXVUF8EALFUMRD:0Y- [IN. CONCRETERO[STALIYq[LLlR:OVw (3M.N° B <br /> APPROX.OMIT s . <br /> 6 E O LOCKXw CHESTER IO)NMTOVE mm S <br /> MOMSEO CONpRUCT10NDnlUNO METHOD: MUD ROTARY AIR ROTARY AUGER CmVE OTHER <br /> I REMY CERTIFY THAT 1 NAVE IMPARED THIS AFnICAT1ON AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH MN MAWR COUNTY OMINAMIG,RATE LAWS,ANO RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY.NOME OWNER OR LICENSED AGENT'S BIONMRT <br /> UM CERTIFIES THE FOLLOWERS:'I CERTNY THAT IN THE RRFONMANCE Of THE YAWK MR WHICH <br /> THIS KRAFT M ISSUED,I SHALL NOT EMROY FEMURS SUBJECT TO WORKMAN'0 COMPENSATION LAWS OF CAUFORIOA.•CONTRACTOR'S DENNIS OR IUs-CONTRACTING sIONATUR CENTIMES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE Of THE W VIK FOR WHICH THIS FEAMIT IB ISSUED.I011AU EMROY RRSONI SUBJECT TO WORKMAN'I COMPENIATON LAWS OF <br /> CALIFORNIA.- THE AJN4M.�A,1MI MUST CAM M NOUNS IN ADVANCI TOR ALL MIN RCO INSRC NONE AT IEOII+"i 21. COMiETE GRAMM AT LOWER AMA RONOEO. <br /> a:e°.f x J 'r PI'LPW1H✓A tul. �PYIIOf 5NfF (7461 071,17- -9,5- <br /> ROT MN V-1°M1.1 hW. I. <br /> I, NAMES OF 6TMFT9 On MAO{NEAREST TO On SOUNOIIO THE MKITTV, l LOCATION OF HOUSE$MACE OI.MSAI SYSTEM OR PMMSEO <br /> E.OUTUNE OF THE FROMM.GIVEN,,DIMENSIONS AND NONTH DIRECTION. EXPANSION OF IMAGE DIBMIAIL SYSTEMS. <br /> O. DIMENSIONED OUTUNEB ANO LOCATION Of ALL UNSTURO AM nwMSEG S. LOCATION OF WELLS WITHIN RARUB OF OHI HUNDRED FIFTY IT. <br /> BTRUCTURB,INCLUDING COVERED AREAS SUCII AS PATIOS,ONVEWAYS,MIO WAIXG. ON TIIE TERI OR ADJOINING RgRRTY. <br /> S 1j T <br /> pBvol Bundrns arm ..4• <br /> f WOr,NHH-. 1 <br /> PIPE. S!� <br /> _. YRP.4D ITL ♦.) <br /> LVE°` C{Y/iEl <br /> �N FFM1 I <br /> Sys' .n•' ° c Irr r.. <br /> f / D <br /> �n. �_�%"•mrd T$ % <br /> h <br /> ° YfE, LY� rNP'M• <br /> YI <br /> _ I <br /> Y GoIssN <br /> OF➢MTMENT USE ONLY <br /> C <br /> A.vlle.lbn Avvsvld <br /> Ore.',.a-By D.I. n-P In,Oellen Br D.1. <br /> 1..0,0100 ImPeKne ar OSM <br /> ACCouxux0 ONLY: AIDE FACE <br /> If CODES FEE INFO AMOUNT EMITTED CIIEC RECEIVED BY DAT! MRMITIIFIIWCE REOUNT NUMBER INVOICE <br /> OD <br />