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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 <br /> (209)468-3420 <br /> 004-NUUNDAILE PERMIT EAPIRE3 I YEAR FROM DAT€133UEfl <br /> rAwgbS1 in TF4Ratol <br /> APFLICATNM(M IR'Af BY MADE TO THE RAN JDAULRN COUMY FOR A PEFOAIT TO CONSTRUCT ANOMA INSTALL INF WORK DE6CAWD-1109 APPLK;ATKINIB NAM M COMPLIANCE WITH SAN <br /> JOAMN COUNTY O,-,VLOMAFNT TIME,CHAPTER 9-1115-3 AND TH/E/R�fjANOATq!OF EAN JCAOUW COUNTY PVRLC HEALTH SERVICES.tMIROHE.IENTAL HEALTH FYMSMAL <br /> JOB ADORESEIOR APN! L (+'r'L AZ'I/'��� .,7�c� PARCEL StlFJAP.I/ <br /> OWNER'S NAMF e AOOIEBI rHOHE• �� l4(- <br /> CONTRACTOR Ca.t' 'C AOdER• Yb J kl lllIY <br /> RUB CONTRACTOR ADOM" LICE_ RHONE/ <br /> TYPE OF VW?LLYl11A*; rew WELL ❑FEPLACE'IAENT WELL ❑MONFTORNO WELL r ❑OTHER_ <br /> ❑DIRTALUTIDN ❑WEIL SYSTEM PEFAM ❑CROS&CONNFCt REPAtR ❑VAPOR EX7AACTI0N WELL/ <br /> ❑N...❑M..o H.P. CIPTH PUMP SEIR, rmw WATER LEVEL O <br /> rI YPE Of 811111 <br /> ❑ovr oP-ertavTCE L.,Eu orDPlnIxAL wEu r ❑ FOR ROTtlNO a <br /> ❑DETIRI/CT1ON• <br /> 1 r W CONS muc io.sploricAtowo A <br /> 'P,(�NDUBTIIAL ❑ RN BOIT: DIA,OE WEIL EXCAVATION dA.Of CONDUCTOR CAMMO yfj-- O <br /> X..'. ATE <br /> T��'GRAVEl PACKISRE, V � TYPE of CASNO/S TEFLIP�IC G dA.OF WELL CARRIO O <br /> �11RN <br /> ❑T� VE <br /> PUBUCAAUWCWAL ❑OIrN TRFTH OF OIUUT SEAL _ RPECIrICATPOPT 1b� A <br /> LJ IOATIONIAII ❑OTHER GROUT SEAL WMTAU M BY IO OADUT BRAANAME E <br /> ti <br /> 40HHORHa OILDUT SEAL PUMFM";7�_ ❑. +- CONCRETE PEOEYTAL■Y DRLLM❑Y. 0. s <br /> APPROX.DBlFH Lomrma CNEMTER IOx18TOVE PAE s ` <br /> PROPOSM CMHTRUC TIOKRXVLJL IMO MINNOO'FEUD ROTAITY�(�ASI ROTARY AUGER_ CABLE OTHER L�J <br /> I HEREBY CERTIFY THAT I HAVE REPATEO THIS APPLICATION AEA THAT 1 HE WORT WILL fIE GONE M ALCOFUANCF LWTN 0.41 JUAOHIIN COUNrY anim ANCEI.SrATF LAWN AND FLUTES Aug\� <br /> PEOHRAT/ON9 Of TI!SAN JOAOM COUNTY.HOME OWNER OR OCEknO ACENT'S PONATURE CERTWMI TETE MLOWNM''I CITRFW THAT MTM REW10 MANCE OE THE WOR(PDR WWH <br /> TMIPERFKT M19SUEO,I S HM Not FAWLOY PVMtM BUBJFCT TO WOPWAAK'S COMPM4ATIOM tAW V OF CAUTOPIAA.'COHEMCTOTe MRM OR IUECOMRACTMO IMNATUAE CEIRIFEB <br /> LL <br /> THE FOOWBNO: THAT M TIIE CE of THE WORK rpt WMCIH jN4 PERMS In IB R/UFO,L SHALL EAIRDY PERBONI RUK.IFCT TO VIMBI'MAM'R CdAFBIBAiIOK IAV/S OE <br /> CAUFOA MA.' T CALL LI iV IN AOV AMit FOR ALL RIaNARMbM1 TONS Ai ILIO!4". ".L'OAKRETE DRAWRNE AT LOWER AREA IRO"MO. <br /> .r <br /> Ksx Trn• <br /> PLOT K I _1.Ie.1.1 9..V 'N <br /> 1.NAMES OF BTFEETS OR ROADI FIEAFEIT TO OR MOWOUM TELE PIIOFERtY. A-LOCATION OF HOUB£SEWAGE Vq OSAI HYMN!OR PII"gM <br /> E.OUTLINE OF THF PROPERTY,0" mm AM EARTH TJo1EC F W. EXPAMWON OF SEWAOE DISPOSAL SYBTEIM. <br /> ].DRAFRMWO OUTLINES AM LOCATION OF ALL EXTETRRO AND PAOIOIM I.LOCATION OF WELLS WTIMN R MK N OF ONE/KINDRED RWTY <br /> ITMICTUFIEB.INERE <br /> CtM"G COVERED AM"RICH XB.AI PAT700,DMVEWAYS.AND WALOW THE PRO/EITTY OR ALPJOOW40 PROF'LTTTY. Y <br /> ..�a K <br /> A <br /> �I. <br /> SEP 2 51998 <br /> sANJUAi <br /> PUBLiC tiL-A;;i,I$�Nvl�l.� <br /> kNvlWNMENTAL HEALTH DWISIU'. <br /> . 1 <br /> —AR­ <br /> WI OMY <br /> ArPlla•HI�,A•w/l.d LEY- \/l O.H. <br /> D,ww P,....Il.n M_ D•1. �/�H�.nP N+p.Ml.n Ir �� <br /> D.I. <br /> n..l..n,l.n Hrv.sM Ir gq r� <br /> 0 1 4 S�CLf R1AI6 <br /> ACCCUNIINO ONLY; AAI FACE <br /> IE COO- FEF INFO FEAOTMT RCA\\[O C !CAIN FECSNEO It DATE PROA TAmwo REOUOT NUMIIR OIVURCI <br /> 1 j � <br /> Pub H94M Serv.-EmEiro.173 Ola?! <br /> e - - <br />