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/ovaOI� PLICATION FOR WELLIPUMP PERM[$ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES rAxC�10> g 3S- C/-3 ENVIRONMENTAL HEALTHDNISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 �� - 1I 9� s (209) 468--3420 D�,e r4 Z?3 - 3 6 2 3 ROK-REFUKDARL1;PERF(TT EXPIRES i TEAR FROM DATE ISSUED (Co Lets is Ttlpf (*J A-1UCAT ION le 1CC.0 BY MADE TO THE GAN JOAO(AN COUNTY FOA A POUXT TO COMSTtWCi ANOAOA NSTALL THE v.?OtK DCGCMGrl)-Ylee AFVt"TION IC MADE IN COMPLIANCE Wnl1 SAN JOAOUM COUNTY OCVCLOPMENT TITLE.CNAFq I:N D-1 1 I S.3 ANO TME GTANG.A=Of SAN JOADVIN COUNTY IAVI,IN N,,/T�_Y PjmUC HEALTH SETTVICEG•ENVMuMENTK HEALTH Oms t4•f-7-7- JOG ADORLS9NR AYH! (3Q- V V V"^ , Ci.- CTIY V 4 DC OMCLL aZE/A('TJf '[� r Ir. /� ZbfJ TJIIII` �«L 4.41(4 / � (A/��Jb Q/ O�•••NEA-v NA"c B l- ��l'�.oc o 'LII I'�, ('l�^7• .':4ADOscas c I&U u�j, o 1•( 4.41 c 4 h�4R/i f .�(J([j-566"i t-- a 2ioi vel#,,few 5A, i 50-4-7E)cr 14TONL)! 27 3-3 23 DONT nAGTOR t, 22 VZ" Ci 11LLQ `-hG A0EN s gkw�G CA '7911/12 (.., T-ve col.innc"Ton c ADCWT" 23 Eh W� Ll!' y� FK 7�S(22�E T1.oN�E k •� J- 87(2- TYPE OF WT•�I,/VTfMP; NEw wlT1`A) ❑ �LACV.gNT WCtL .�NOIf7'OPMIO w1:u./ i.�-� 101 OTNEA 3 FCw�[�i#J,(TIT loch 5 Cl MBTALIAnom ❑WELL wnrt t R£TAfA ❑ cito G1CONNCCT REPAIR wR'l( ❑ VAPOR EXTRACTION WELL/ ! fes' f•CI«5 C l� ❑N...,.❑P-4 N.P. DeoTx rwn 6ET .r_ "ReT WATM 11vcL (�3 4 t+7`^tom ❑ CUT 4Or-rrnvrE Vll LL ❑ OCO✓H\1:1CAL Yllu / lJ cO2(50�NG__ E LJ OF 4'i ulKTb N; �!i'Vt'I\��4.J Wti I� INTCJIDCD U6E7-mal-RUL CONLTRUCTION 4PECIP4CATIONa A' ❑ P.OUSTRIAL. ❑OPEN BOTTOM OrA.OF MIEU,EXCAVATIDN ✓TTO,'/j �}!� OIA.Or CONDUCTOR CASwO O ❑ OOMEGTTCWWVATS PtORAv6L PACKIME Z 1�- TYPE Of CAwM19TXe)VVC I•v G 0.-OF wMt.CAS-4�3>�4- ❑ nrat.IC/ Ut.CiPAL ❑DRIVEN DEPTIA Of anocrr ZEAL �''T� SPECW10CATION R ❑ rpwOGAT'O"IAO ❑OTHCR OROUT lE L t9v^LED OY 7-}C O.I; QCGr- OROUT BRAND NAME �tONfTORINO / / c7 ` ORDUY[CK pUNPLO:my— ON.. COHCtTfTF PEO(BTK tY OR7LLCR❑Y.. ❑Na S APRIOX.DvTw 3n j I X p S LoCIUNo CHCOTEA GOx/GTV VC Pa'C S ta MOPOOM CON[TRUCTTON(DAtLU140 IACrW)0; MUO NOTARY AtR 1gTAAY AWFR��IO�V r 6LE OTHEII �lannp ;fl; I HEL'OY CEKTIFY THAT IIIA FVWrAJt(O TMG AVWJCATXM AMO THAT THC WOtK I„RL"DONf M ACCOPOAMCC VAM BAN JOAQUIN COUNTY OfmWANCM STATC lAW4•AND PIUL.EC AND REGULATIONS Of TME SAN JOAOUIN COUNTY. H0►.1C OWNER OR UCENGEO AOEJIT's OtONATUNd CUCTWfES THE POLLOWINOs.1 CIZATIFY THAT M TME PSM10NMAMC Of THE WOPIC POR WHICH TMt P[imrr Ie tGGL1F0•I MALLW KRGONe sv6JCCT TO WOfWwAK•c Come% 5#,Tt"EAws OF CAUfOWA.' CONT ACTOR'S$Mt Q OK RUL SONTr.ACTtNN O SIOATUREI f CMRlit THE F+OLLOWINO: CFJTTIFI'7 AT W IE ORALAwCE OF TMC WOK MA WMICH TWO PE/tKR IS IGIITAIT.I eNALL EMPLOY PERGONO GtMJECT TO WVRIWAN•t COMV"4ATION LAWS Of CALIFON+tA_' A N HOUR.IN ADVANCE FOR ALL NECIWID INVCCTKfN4 AT tzoel =--4 COUR1M ETE AWtNO AT WOMA AREA rWvtOEO. Tr��;1 f�LO rCJ�nt to— 0.44 4a�� te . 1. NAAREB Of OTREET6 OR ROAOS NEAR£BT 70 OA nOL7NOIN0 1'NE PpIOP£ftTY. A. LOCATION OF HOUSE BEWAOE DIGPOVAL tYSTfM On 1Y orloSW 2. OUTLWE OF THE rr.M TY.Gr4M 00AENSIOHt ANO NORM D ECT1ON. EXPA"MN OC CCWAOE tXWOSAL SYSTEMS. 3. D 4CHGON60 OV"J Me AMO t.00AT1ON OF ALL E7KTtTtsq.KNO PAO—OW t. LOCATION OF TNCU..t Y+TTN1N RAOMe OF oto IRIHURm 4TFTY FT. sTf ,LCTM¢r.INCLUOM COV4tt0 AMCA11 SUCH At FATKM pltVkWAYO,AMO WALKK& OM THE t'RDOQLTYORAOJOI►ONO FMP>UtTY. /��..�.•�. .. .. .. .. .. ........ .a - 1111 . . . . ---. . . - .. . ............ ....:. ...� . . 1111 .� ... .. l�IJ.P K �. J�i �LT f•• f •`• -•...-... .... 111:1 �•• , • .. .. ''.Y!'El)u4W.`,�.1 ..t° :\e(R ,t.On_ .( tl &-it &.I{.•:+ _ 111{1. ..i. .i.............y...... ..... ........................ ........................... ....... ............. , 07 S-(, 4...t M....+1...tY �x..Q �,CO//� �-L�C� `YG'1. �' „�I �✓ __'T,e.�• ,�wf��yr,^� �rlrl1rl, �S Cirw y • INIOV 04 179 c L, r - ;o s N V!RQ itJ IVl. - cep, p 1 =u ACCOt/HTINO / S F f "ES - - fACI PECovu PH two AMawrItUA=w !CASH It6C.9VfaDtr OAi! rum IMlRY=R UCSTIEtlIMCR �HEvo10E