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P. 2 <br />11—OS-1997 1:SSPM FROM <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <br />344 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 458-3420 <br />110s•R UMDABLE PERMIT EXPIRES 1 TEAR F1ION DATE ISSUED <br />(CampLa IS TripSeNtai <br />APPtKATION IS IfERE EY MADC TO THE 81.4 JOAOVM CVNfrY FDR A PEIOJIT TO CONSTRUCT Abd=,, WWM.t T1 C- %4.vW OECCWBED. TUM APPLICATION M MADE M CO"PIJA+ICE "fTll SAN <br />JOAOUW COVNTY OEVtLOV%A0(T Yrtlf- Cs1AYTEt 9-111 S.3 AND TEE STANOAA09 OF SAN JOAO(M COUNTY MOM "Z^LTH 9. FOVWX)+°.q�NITAL HEALTH OMs4 <br />0. <br />! LGH Cm / <br />CITY ( Oj1 vA1ca�IAPru C'�S��yUZ <br />Joe ADOPXEssIDR An+i n <br />owHtn 9 .ILL v G .. Anol:Eas V () lJc�k bCY� c / P�+�E v� Zs - G�JL 76 SS <br />CONTRACTOR 51=� Uy1 -✓r(lr>c.�u c 1nU AOOAf11IZcxC Pce/rfcPnx I h/� <br />S19is r/6 <br />q1�& <br />9W CONTRACTOR i0 !_I �C Zrv�!-7 I n ��1'ppA(t7 3 Z -J Gl ��Llf -.�'C{ �� llC•ss"7 �?� PHONE P / r /� <br />J � <br />TY9f OF VeFu'rUAIP, ❑ wFw WELL ❑ P"LACOACNT -TLL B WOwrop 11O WaL I LL--- [S ❑ OTTIETI <br />❑ RIBTALLA.TMOR ❑ WtLL 9YSTET4 REPAIR ❑ CAOBSC*kvgCT WACP ❑ VAPOR EXTVACT10H WEAL f <br />❑ H... ❑ FbPr• FI o- OEM" Knav' BET !T. FWW WATER LEVEL <br />(TYPE OF PJMPI ❑ gorL SOIOHG <br />❑ ouTOI'QCAL WELL, F -SERVICE WELL ❑ OEOP✓E• <br />❑ OE 6'IRVCT qH; <br />INTENDED Ulf <br />TY7E Of WFLL <br />CONA7wU07rON APECIRCATIG Hi <br />WELL EXCAVATION O I <br />Dw OF CONDUCTOR U8AJ0 <br />❑ *,OUSTR<AL <br />❑ OPEN BOTTOM <br />Of A. Of <br />-7- <br />❑ <br />❑ GRAVEL PAC%:IWZE <br />TYPE OF CABI/JICJSTEtl w%'c ID ✓G <br />DIA. OF WELt CASTNo 7 <br />oOMEBTW--WVATE <br />❑ PVSLJCA0jW$CIrAL <br />C] <br />❑ Or4VEN <br />OEMH OG C"OVT SEAM - SI'L I . Sf., -!S ��) SPECIFICATION <br />❑ MR QATIOWA6 <br />❑ O`TrER <br />WtOUT SEAL *MTAU M BY <br />❑ <br />GROUT BRAND NAAAf <br />cOHCR£I•E PEDESTAL HY DALLCR ❑ Yw ❑ Ne <br />GOOVT SEAL PUMPED: ❑ Yr n• <br />�anOlrtTOTaF10 <br />COC MGG CNETTER BOXJCTOVE PIP£ <br />A/PIIO X. Dfllrll <br />Arlt ROTwRY (l C ,1LK7fFt <br />OTliEA <br />s OPo6En CONITM)ClTON/OIi-P- ME7H00: IMA MTARY <br />I IiEVE1E1' CERTIFY THAT 14AVE I`REPA/1E.0 TMC APPLICATION AND THAT THE wORK WRL SE OONC M ACCIDIMANCE WITH SAH ?OAORRN COUNTY OfCOwANCE9. STATE LAWS. ANO IMF1 AHO <br />ck <br />MOLPL (TIONS OF TNT CAN JOAOUTH COVNTY. HOME OWNER OR L)CEWSED AGENT'1 SIGNATURE CERTIFIES THE FOU,O%QDA: 1 C1:RTgY THAT N TNR P£WOIOIAAMCE OF THE KOPK E C KT WS <br />T HfB v>=lusrt to 186'11E0. 1 B+IALL ►qT EIf1�0Y t+tRA049 6LJ61ECT TO IVOR+X/.lAx.1 C,01AP0 9ATION LAwB OF CACIFORNTA.' CONTRACTOR'S FffPINO OR SLID-CONTTtACTRrO 6=GHATLRIE CERra:TEe <br />THE fOLLp`i.TH(I: 1 CElrrlfY TT1AT IW TiIE pcpwow1.aANCE OF THE WOFK FOR "41CH Trig PERNT to I8OUED. I eHA1.L WPLOY PEPSOM tVS.JECT TO ylpRgAAlri V1000 ET'IUTION tAWf Of <br />CAJ07$$IA- T 'Ap�uc:: C WrU" M �A�i f� ACL WOLOK0 f"PVtTtord Ar DO" Ao sl a. COMsuT! OAAWIH6 AT LOWER AsaFA PPDVQ7EV. <br />� s-- <br />PLOT PL" gn- .I- S --w gar. SAL srsTEf+0PRO OSED <br />1. NAMES Of 9TREETS OR ROADS NEAAE6r TO OR VMWDING THE PROISIRY. <br />O <br />Z. OVTLIHR of TI+E ppPRRTY. OtVTHO OVAENBIDNs AHD NOITTI( OIR£CTlow. <br />I. OIIAENfao UED OVN <br />TVWS AO LOCATRTfI Of ALL EXIS'TIFIO AHO PP✓OWBED <br />LTRVCTVRES WCLVOI4o COVERED AApr"Sl1CH A8 PATIO9. DRNIWAYS, AND WALKB. <br />�. LOCATION OF HDUSE Sl — 018FO R <br />EXrAbt ON Of SEWAQE DtWFOGAL Qrs•TEUS- <br />6. toc.AT10N OF %%Tt Jl WRTIO( FL&MV or ONE 1R;Wap`Fo FSTY FT. <br />ON TIE PPOPERTY OR ADJOW410 PPoVERttt. <br />pgMTrw pqT IRE OMT / e <br />CJS C <br />Dw• kr <br />A�Ir,.Nu.. Aa••oa.d Sr l\ ,,.1�-e�-'�/ \ D•t• <br />O.f• VkL v 4.P•ab++ BT <br />ACCOVNTI110 ONtrt I <br />r% coots , FEE goo � AIAOUNT,TEr,rITTID <br />Put). pAatrh Sem - Envi-- 173 (11971 <br />FAC♦ <br />cf=%IFAAH I vTcevEa tY <br />rz' <br />VSr mr,SERVICE NEaMT MUNISCR vIVOKI <br />(;v-00ZZ? `41 <br />