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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOADUIN COUNTY PUB11C HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,344 EAST WEBER AVENUE.STOCKTON,CA 95201388 <br /> (209)4893420 <br /> RON REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> IC•mpININ IN Tdvrl N1N1 <br /> APR ICAT IC.N In HFAF MY MADE t0 IHF PAN JOAOUIN COLNETY ION A DF—T TO CONSTIIUCT ANMA)R INSTAIL THE WON(DESCRIBED.710E AKLICATION M MADE IN COMP,IAW WRH S+N <br /> JOAOUW COUNTY oEVFLOpMfW TRIS.CHAPTER 8-T l l5.3 ANO THE aTANDAMTIR OF RAN JOAOUITI COUNTY FVBLIC IIEAL711 SERVICE8.ENYIIONMENTAL WALT14 DIVISICN. <br /> JOB AVORERBVOG APNI r 1 n <br /> CI I f /■�L�(/�t;//`/J ��� PAROL a1ZElARJ/_ YR,( <br /> � <br /> ONMCR'S NAM,_ l C A/ i <<�� Pcc QL C/a�ARDPfaa �('%'�? /y�/[�$G y �['l /fUV.ONEI J36—j/,;ls <br /> P.DNI NACTON i c?S*rJ �4 111 u: <br /> WN CONTRACTOR_ A !7L_�E �`�3 IICI PHONE• <br /> TYPE OF YYELLRUMP' ❑NENWELL ❑IIFR ACF--WELL ❑MOND OPINn WSLL• ❑OTHfN <br /> ❑FT INBFFApLLATION ❑WELL!]'S I EM AFFAIR ❑CROPR(:RNNFCT WPAIN L1Po <br /> VARE%7RAC ION WELL• <br /> tj ,. <br /> HP.�y OF'H Dump BFF�_FT, FRUIT WATER LFWL- <br /> RYFF OF 11"11 Tom^ <br /> ❑om OC CEMVICf WFLI ❑nmmymm WFII I ❑ BOIL MOFF: e <br /> ❑DENrRIFcrpN; <br /> INIENOED UE[ TYPE OF WELL CON S T RLFCTION AK CIEIC�TIUMS 1 �F� <br /> ❑INOUSTIPAL 11 ON"BOTTOM CIA.OF WELL E XCAVAl10N DIA.fRFCONOUCTONCAEFNO li ryr <br /> 11DOAIFSTICOTVVATE ❑GRAVEL PACK-11 Ty,f.DFC.ASINOIFIHIRVC DIA,OF WELL CAall O Q <br /> ❑PLIIILR:GAUFIICIPAL ❑TNSVEN DFPTII OF ORO-SEAL SPECIFICATION \ <br /> ❑IF/NOAIIOMAO ❑OTHER O-OUI CFA!INa7AI1 FD MY OROVT SMF-NAME <br /> 11tpN ❑,-7 <br /> G MONITOONOUPOM <br /> I SEAI rTO.BY. ❑N CONCNFFEPEbESTALBYbRLLER:❑VF. NA <br /> Ap,ROW.OEnH LOMING CHENTEn Boxmic,iE RPET <br /> "NOPUSFD CONSTNUCTIONIDWLUNO MFTFMO:MUD NOTARY_ AIR RIOT AAV _AUUFR _CABLE OTHFII ' <br /> 1 IIEMESY CER71/Y 714AT 1 NAVE P1IEAARM;b TN1S ANRJCATIOH ANO THAT iHF V1nI TTI.HALL FIF DONE IN ACCOEDAWT WITH SAN JOAOIMN COOMY ORDINANCES,STATE UWB.AHO RUIFa ANO \ <br /> nFnIn ATI <br /> ONS OF THE SAN JOADURN Co.—.NOW OWNER OR LICENSED An,,Mr..NATI)ME CfFITIFIFS DIE FOLLCWSM:'I CERTIFY THAT IN THE FEWOFBJANCE OF THE NbRK/OR IaEACII C{ <br /> TIRE PERMIT IE ISSUED,I a11ML TMT EMPLOY PERSONS SUBJECT TO WOAWMAN'5 COMPENILA TION LAWS OF CALSOWIIA.•CONTRACTOR'SHSSNO ON BUB-CONTRAC7I0,10 MONATURF CERTIFIFB L/1 <br /> THE FOLLOWING: •1 CERTIFY THAT IN Tiff PERFORMANCE OF THE WOFR FOM WIIMCH THIS"FN—If I8SUFM 1 SHALL EAIELOY PERSONS SUBJECT TO WORIOMAN'S COMMOADON IAWS OF <br /> CAI-NORMA." THE CANT MUST CAL//L LII IID W ADVANCE FM ALI RTOMRFO INAPECTIONB AT 1SSS1 AS 22.COMRETF D7IAWINO AT LOWER A11EA fTO VIOLA. �+ f\V <br /> Nan.•r_ /�A lL•v'V_ ,r D.I. <br /> 1'L0/PLAN S>•M ro 4wI Rade _ <br /> I.NAMES OF STREETS OR 110ADS NEAREST TO OR SOUNOIFM THE FA'J/TRTY, A. LOCATION OF HOUSE SEWAGE DISPOSAL WIFfEM On F,,vfV"V <br /> 2.OUTLINE OF THE PFOKRTY.OIVWO DIMfNeIDNR AND MOM"DIMP-10H. EXPANSION OF SEWAOF DINFOSAL SVSTFMC <br /> O.DIMENWNEO OUTLJNf/AND LOCATIDTI OF ALL EXISTING ANO PNOPOSFo S.LOCATION OF WELLS WDIVIN MANUS OF ONE HUNOKO FIFTY FT, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIO6.DRIVEWAYS,AND WALAS. ON THE FROPEMY On AOJORNNG PMOfENiY- <br /> a <br /> FFr1t <br /> �� DEL' 4 <br /> N � <br /> Iia <br /> DEFMTMENT USEONLT <br /> NFIIFF111n ATa.pl..l Ny q��� z r�, <br /> DEI. <br /> dN,T 1nFPm0A..ST DSIP FWnp In.p«�tla.SY �T)rFI 9-�z-�� <br /> O.w..�IMIn IMnrllmRv <br /> ACCOUNFINO ONLY: ANN FADE <br /> K CODfr FEE INTO AAROUIIT RE7.11T TFD CIIECW CAFN l RECEIVED/Y DATE ISM AITNI.CS NEOUEIT NUMSIEI INVOICE <br /> Pt,O.Health Sery.-Ewro.173(3196) <br />