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;PPLICATION FOR*ELIIPUMP PERMIT SAA JGAOUM eOUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,304 EAST WEBER AVENUE,STOCKTON CA SIM01SB8 (209) 469 3420 NOW REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CBepNEE M TrWhufeI 1CA7ON 11 HER BY MAGE TO THF CAN JOAOUN COUNTY FOR A PERMIT 1.CONSTRUCT AND/OR INSTALL THE WORK DESCRB[O THIS APPLICATION 15 MADE IN COMFLIAHCE WITH LAN OVNI COUNTY DFVFLU`RMvwT}TrELE CHAPTER$1115 A AND THE STANDARD!OF BAN JOAOUM COUINNFY PURUC/HEALTH SERVICES ENVIFgNMFNFAL HEALTH DIVISION JOS AOORISA3R APF/H ��U. !.✓.{ I ,_,]/,C4T�4. ___P . rAFKEL.111AFF11 OWNERI NAGS / f! GA' APDR4Yf Jy)J [ NJ J h' I� F• k4. PHO_fNE,(.LY��1 Ll�Tf evw--.r , r CONTRACIOA>T,moi r � , % (- T�_ AbbRli�%�//J r / S/ 7 elc, r t//>!' PHONE SUS CONTRAC7 On ( L/I �� / ✓7 ADDRESS 7 2 r i J. / / LIC• �F r 4/Y'�i MOVE I�Jf)f + 7.17f F�1 �T / TYPE OF WELLAr MP L)NEW WELL ❑REPLACEMENT WELL MONITORING WELL/l�L'E - ❑OTHER 0 INSTALLATION ❑WELL SYSTEM REPAIR CIni7LOHNECT REPAIR ❑ VAPOR EXTRACTION WELL F .! 11 N_❑Rwr. N P DEPTH PUMP SET_FT FIRST WATER LEVEL O STYPE OF RJM F-I BORING r / /❑OUT-0F-RSERVICE WELL ❑OESL OPHYCAL WLL/E / LJSOIL BONG S 7, CADEiTRLM.'TION WI b syi Fr. Ji/ i I J I. f.r rI,/fi f r+wi f e-,r- r tel/C/ ...t/.F INTENDEO Ulf ry—F OF WELL Illr CONSTRUCTION SPECIAICATIONS .r�rnirr.iri.r� A ❑NW$TRIAI L UMN BOTTOM bIA OF WELL EXCAVAT/ON r DIA OF CONOUCTOR CASINO D ❑OOMEST C rHl ATE vl GNAWL PACKMIZE TYPE OF CASINORTTEFL/PVC G��i fff / INA OF WELL CASINO O 110 PLPWJCIMUH^IFI LJ ORYEN DEPTH OF aNOUT 9E41 SFfCIEICATION R ❑IRRGATHpr A, L)OTHER / GROUT SEAL INSTALLED BY GROUT SRANO NAME E ❑MbNITTIRHG `e GROUT IEAL"PEI) ❑Yr ❑Ne CONCRETE PEbESTAI SY LIRJUJFL❑Yw ❑N. $ APFROIL DFT M _ 1 EOCRENO CHEFTER OORISTOVE PIES 5 PROMSEL CONS"MrIONIORLUNO METHOD MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HFRElT CF REIFY in• I NAVF PRAIrED THIS APPLICATION ANO THAT THE VA1K WILL BE DONE IN ACCORDANCE WETH SAN MA04MN COUNTY ORDI F1NANCES STATE LAWS AND RULES AND ROULAT(ln Ct Ts., N JEI N rOUNTY HOME OWNER OA LECENSEO AGENT S SIGNATOR OERTIFIES THE FOLLOWINO I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WNICH THIF FARM i 1F IFSJLr I SNALI NL 1 VRCY PERSONS SUBJECT TO WORKMAN i COMPWSATIOIF LAWS OF CALIFORNIA CONTRACTOR S HIRNO OR SUStOHTRACTNO SHONATUR CERTIFIER TNF FOU +^ T CER + 1N• I Irl PERFOR.IANCE OF THE VAR(FOR WNICN THIS PEMIrt 1B ISSVED I SHALL EMPLOY PERSONS SUBJECT TO WORIOAAN/COMPOISATION LAWS OT CALIF 1MI, rEU A'PUG RFE NIUF♦PAI]74 HOURS IN ADVANCE FOR ALL REQUIRED INSPSCTTONS AT Itopl MS-SAAB COMPLEr[DRAWINO AT LOWER AREA PW"DED f,��— -- TRI._!/E [f/ J' L. . c J/ -----DM. 7ZL J / RD7 RAN fpwv le SaY.1 Sub 1 N.W ES 01 VM-rc 11,WADI NEARLST TO OR SOUHDINO THE PROPERrY a LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P"OPOBED 2 OUTIJNE OF THE PROPERTY OMNO DIMFNSIONI AND NORTH DIRCTIGN EXPANSION OF SEWAGE MOPOSAL SYSTEMS 3 DIMENSIONED OUTUIIFS AND LOCATION OF ALL EXISTING Amv PROPOSED S LOCATION OF WELL@ WrMIN RADIUS OF ONE HUN G 74FTY FT STRUCTURES IHCLUDINO COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WAUUB ON THE PROPERTY OR ADJOININO PROPERTY I DRMTMENT LRE ONLY rf / 1h A,_ O M S�F,M St --_-- / O I• Mr NrFSH.n•T D.I Do. c-._J,. S I L 1 I r I' _ A ACCOUNTING OWL AAI FAC, HH CO9U FEE Hf`0 AMOUNTR9�STTED WCf(/ICASN RFCSEVTG FY DATE ►9VAITMO 11!MOUSAT NUMBER INVOICE