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APPLIco LGN FOR WELLIPUMP PERMIT <br /> SAN JDAOU'1 1'JNTY PUBLIC HEALTH SERV16t:S <br /> ENVIR-YIENTAL HEALTH DIVISION <br /> RO,BOX 388,304 FAST WEBER AVENUE.STOCKTON.CA 95201388 <br /> 12091460-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES L YEAR FROM DATE ISSOEO <br /> ICelnplol/Fn Itlplkat{I <br /> ArrUICATION IS HERE BY MADE TO THE PAN JOAOUDJ COUNTY II Eon A PFT TO CONSTRUCT AVOIR"INSrAIL THE WOIIT DESCRIBED.TIVS APPLICAIEON PS MADE IN COMPLIANCE VNTH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE. <br /> TITLE.CHAPTER 9.1115-3 AND THE STANOAAD OF BAN JOAOUIN COUNTY PUTILIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, <br /> JOB MDREBSIan ArN1 � 1 x t p Q f� (� tlrr_ .l V C 1�tVII <br /> 7 +1 M Q n i ALL_ ( PARCEL AI1E1APH ,,J <br /> OWNER'S NAME / Y. 7 t VPI mar Y 'I 1e AM)RFSO r V/ 4{�� I. 1� / (]l I 1((�( PHONE I 7.J Z <br /> CONIMCTOR_. KV4fl(/L( _✓�f �HIII/GI?Mte AODIIII f�f�I� W (}irt II ty� 7PHONE It <br /> BUB CONTRACTOR---fl-11— Yf 'I 1I��AE ADbREs¢ <br /> 1'� <br /> V}Cr NCN p T'iIONE/I-YrJ-yfs-7j i i <br /> TYK OF WEU-TVMP: ❑NFW WELL ❑REPLACEMENT WELL VAI MONHORINiI WF.IL f� E'J ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONWECT REPAIR ❑VAPOR EXTRACTION WELL/ <br /> F <br /> Ns«❑Itepell H.P.— OEP1H <br /> /UMSET FIRST WATER LEVEL__ <br /> F1 O <br /> OuT.OF SERVICE WELL ❑aFO"IYSFCAL WELL f ❑ SOIL BORING <br /> �y A <br /> L-1 OEBTRVCTION; <br /> INIFNOEO VFE TYPE OF WELL CONEIRVCTION SPECIFICA TIONS - <br /> ti A <br /> INOV6TPohl ❑OPEN panDM DIA,OF WF1[L%CA VhIION <br /> Ft�� ' " Q DIA.OF CELL CAST R ChA1HO wA O <br /> ❑IIOMFAIICnRIVAIF t'�ORAVEL rACI(lAITE 11 TYPE OF CAFINOIfiiLrl/N rl In <br /> ( OLA.OF WELL CASINO/ f- D <br /> c❑T PUPlICIMVNtCO•hL ❑OIOVEH DEr1It of anoUT SEAL ] PPECRICATION L y[ <br /> U IM"ATIONIAO ❑OTHER R <br /> GROUT SEAL INSTALLED MY 1 Yelry 1 L19 MONITORINGGIOUT BRAND NAME AAr hA d fgp, <br /> /.F - E <br /> '/.7/I} anoUT SEAL PUMPIr—I Y. LI'LNe CONCRIF!E PEDESTAL BY OFILLER:IRR- ❑Ha $ <br /> APPAL OEFTN__ Y U LOCKING CIIEBIER BO%TATO VE 1`IPE VA <br /> PROPOFEG CONATRuc TIONR1E11111N0 METIbO; MUD 110TAM AIR ROTARY AUGER._ � CABLE <br /> OTHER 5 <br /> 1 IIE9EBY CERTIFY THAT I HAVE PREPARED TNI-A11-11ON AND THAT THE"W WILL BE DONE IN ACCORDANCE WITH BAN JOAVUIN COUNTY OMINAHCES.STATE LAWS,ANO RULES AND <br /> RFaUTATIV 8 OF THF SAN JOAOVIN COUNTY.NOME OWNER OR LICENSED AOENT'e SIGNATURE CERTIFIES TNF FOLLOWING;'I CERTIFY THAT IN THT PERFORMANCE OF THE WORK FOR WHICH <br /> THIS 1YRMII IB rSAUE b,1 SItAIL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPERGATION LAWS OF CALIFORNIA,'CONT PIACTOR'B AIRING OR SUB-CONTRACTING SIGNATURE CIFF101 B <br /> THE FOLLOWINO: -1 CERTIFY THAT IN TIFF PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED-1 III EMPLOY PERSONS SUBJECT 70 WORKMAN'{CGMPShISATTOM LAWS OF <br /> cAEJFORMA.' TIt,E APPUCA7NT MV{T CALL 14 HOUIE N ADVANCE FOR ALL REOUMian INi►BCT1oN/AT Ill 1e/121`CGMrL11E DRAM-AT MOWER AREA—141,111- <br /> III X­ !/// ✓ --r �c�l�'� TNI, —kill V.01 YNIAi _) Yf�LrW <br /> `. <br /> ROT TIARA 1E Tphew In Reel„1 Reele Ie <br /> 1,NAME{OF PTiTFFTB OR PAAD01H0 1 <br /> B NEAREST TO OR POVH1Of`ERIY. <br /> Z.OUTLINE OF TIIE PROPERTY,GIVING DIMFITMIONS AND NORTH OInECIRTH. {. LOCATION OF HOVST SEWAGE DITIMPAL BYBItM OR P rwq, GED <br /> .S OVIIRIFR AHLOCATION OF ALL t%FIFTHRR AND MrIPOSFH E%PANAPON OF SEWAGE DISPOSAL BYB/FMB, <br /> 6 D TnVCTVAEB,I"CLUOINO COVERED AREAS SUCH AS PATIOS,DMVEyVAYS,AND WA.LXS, Or LOCATION OF WFLtB WITHIN RAINVB OF ONE HUNDnEO t1EtY FT, <br /> ON THE PROPERTY On ADJOINING rPOFEn1Y, <br /> LE Copy <br /> .......... _..... <br /> IMPARTMENT VOW ONLY <br /> Aepneetbn AeewlaeP by ,Y I ��'f I Q/ <br /> /� Oeee �E-•--r(-1E��Aru <br /> Grout I,wP1a[len DI b,te b Q I Imreellen By <br /> Del. <br /> b+.utslMn Irul,r..[lon By <br /> bete <br /> cmnrnr.r.: 11C� �vtC-C vAUL 1 comP ruct"A <br /> ACCOUNTING ONLY: AFbf <br /> FACT <br /> PE Cant/ FEE INTO AMOUNT RDwTTED CHECI[IMAMI RECEIVER BY GATE PERMIII/FIVICE ROGUERY NUMBER INVOICE <br /> Pub.Health Sem.-EnVIrO,173(3/96) <br />