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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 F1,13 2 2 <br /> COPY (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Icempble In <br /> Al"ICATION III lfFRF IIY MAGE TO ME RAN JOAOUFN COUNTY FO"A PERMIT TO CONSTRUCT ANDIOR INSTALL TIff WOW(ASCY"RED.TOII@ AMICAftON in MAGE IN COIL4r'tIXNCC Mill CAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1 116.3 AND THE RTANOARMS OF BAH JOAnuiN COU IC IIFALTII$fnVtqff8.ENVIRONMENTAL IOF.AtTli noVISION, <br /> JOB ADI)PIERRIOR APIA Cory_114j �17/JW f4P yjd&Zk7:;7 <br /> PARCEL SfZFjAPHf <br /> OWWWO NAW <br /> : ADD 4 "IOmq <br /> V <br /> CONTRACTOR ADnF <br /> -le-11 -e-jo-111W1131 PlIONE <br /> v 41 1 • <br /> OUR CONTRACTOR LICE PHONE 0 <br /> TYPE OF WKI.MUMPI 0 NEW WELL 1WREr!.ACFIL4fNT Wftt 0 Momorram"WELL it 0 OTHER <br /> ❑ 049'FALLAVION 13 WELL9vS7 EM REPAIR 0 Crt098-CONNECT nfl'AlFt 1:1 VAPOR EXTRACTION WELL dr- <br /> I)FP1rH PIMP SET IT. FIRST WATER LEVEL a <br /> ouT-or-innvocs WF.L <br /> 7,(j otorotypicAt WELL0— ❑ BOIL RORIHO <br /> I - m'"N. 7'1 <br /> f IF <br /> U6Eyps 0 <br /> ry A <br /> MAL WELL DIA.OF tL EXCAVATION DIA.Or CONDUCTOR CARING��=IITICtMVATE L3 GRAVEL PACOUGIZIE_ TYPE OF CA91HOMTEFIft-M DIA.OF WELL CASINO ROW— <br /> ❑ PUALICMUNICIrAt 0 omvtu OfrTI1 OF GROUT SEAL I;FTCWtCAIION R <br /> MMOA-tIONIAG 11110117'SEAL tN9TA1-!_FO 9V GROUT BRAND NAME OF❑ I <br /> MONITORING GROUT SfAt.PUMPED: 0 Y. No Na s <br /> APMO)r.DFPTH LOCKING cNesTen a XMTOVIE OWE s <br /> PROPONtO CONST111,0017001MMUNG M&11`1012: MUD ROTARY AIR ROTARY AUGER CA" <br /> I fffWRY CERTIFY THAT I HAVE PREPARED THIS APPI-ICATION AND THAT THE WO"K VVI1,1-RE DOME ON ACCORDANCE WIN BAN JOAGUIR COUNTY ORDINANCES,OrtAlt LAWS.AND nULfs AND <br /> REGULATIONS OF TOOF SAN JCAOUIH COUHtY. HOME OWNER OR LICENSED AGFM'g 910"ATU111!CEATITM8 THE FOUOMNG!'I CERTIFY THAT ON Tiff PERFORMANCE OF THE WOW FOR MtICtj <br /> ims PrRPJIIT 19 MRLNO,1814At <br /> -t Not EMPLOY PERSONS NfflJtC1`TO WORKMAN'/COMPINBATION LAWS OF CALIFORNIA.' COWFLACTOR'g tPRINO OR OUR-CONTRACTWO 910"ATUM CEM IFIts <br /> THE 1101-ILOW11410i 'I CERTIFY THAT IN 77 <br /> T17 C 15 RMANCE OF 1" WORK FOR WHICH 7100 PE 19 18"0.1$1,1ALL EMPLOY PERSONS SUBJECT TO WONIOWAN'S COMPMOIATION LAWS OF <br /> CAUrOf"A.' THE CANT M I CAI IN A7ANCII FiNt ALL REQUIRED <br /> WD INS Air 14011�11O`1211- COMILIFTE DRAWINO AT LOWER AREA PROWOFL". <br /> 4— <br /> alf—d XToot— 4L-- <br /> VU <br /> I MZ I*so-iol p to <br /> 1. NAMI[//r9Tf1*7" NEAREST OR ROADS AST TO On ROM=TO PROONFITIV, 4. LOCATION OF IfOUGE#tWAOT 049MOAL OYSTM On FIIOPOSFD <br /> 2. OU"OUNIE OF Till PROPERTY.GtVINO IRMENS10"11 AND WORITtr-MC110", EXPANSION OF SEWAGE DISPOSAL SYSTEM!. <br /> 2- DIMMMONED 01,171.010.0 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WIF1,1.8 WfTHIH RADIUS OF ONE HUNDMb tWTV T-F, <br /> 11TRUCTUME9.WLUOINO COVERED AREAS BUCK M PATIOS,DRIVEWAYS,AND WALKS. ON THE rmpEmy an Ami"m Pnomm. <br /> N, 1 la <br /> -PA <br /> YFA E <br /> pr "r p <br /> FEB 22 1999 <br /> is <br /> Pu <br /> V1110 Ir <br /> FdN \. <br /> .......... <br /> --41!....I...—................... ....... <br /> Of TMtHT USE ONLY 70R-1(4 i <br /> AppPlopti—A-.Pt.A Ov 442� a.,. 7 , 2-2-A/af At" <br /> 2 <br /> aL <br /> *4WC-X,,A (-rj 0,r 044ATG rAAA-, JLIZ,01 d 4! -LV e- Fie e e:-jZe <br /> ASA"" <br /> ACCOUNTING ONLY; AID# FAC$ <br /> PE CODE/- FEE owe AMOUNT q REMITTED /(CII�ECKAIIH RECEIVED BY DATE PERMITijurAcE ReautEnT Numarm INVOICE 11 Le) 0/ pq-1V <br /> 0( <br /> ur <br /> cj <br /> Ll Lcd7l.....20 — 0 1 Kqj(r <br /> Pub L419allh Serv.-Enviro.173(1/97) <br />