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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) 488-3420 <br />11011.1IEFUNDAILE PERAuT EXPIRES flu MN DATE ISSUED <br />ICeleplete Is TrIplestel <br />een ICA.1011 PS NEM FIT MADE TO THE SAN IOACP/IN CoUSITy TOR A INERAIT TO CONSTRUCT ennoon METALL THE WORK OWNING. TIOI APPLICATION IS MADE IN COMPITANCE WITHEAN <br />JOADT/IN COUNTY DEVELOPATEw TALE, CHARTER 9-1 1 15.3 AND THE ST ANOMIE'S OF SAN JOATIUIN COUNTY PUIN/C MEALTI1 IT/PACER ENVIRONMENTAL HEALTH ONTRON. <br />JOI 000RE504011 AINe gtf. crier CI 41.e 3 2 <br />z <br />rAPASEL4IrErArNI <br />MAMA'S NAME (1.'0 4,2 A. ADORE., )4c, /MirAic.14) .1:54143..I • a <br />core RAC raft ( -a., Pciio If S9 IC A1Xr.2 .• PHONE "7/4 <br />NVO CONTRACTOR ADORES• PHONE <br />TYPUOF WDUTJMP: 0 NEWSOM <br /> <br />0 REPLACEMENT WELL <br />5. b o 41444. PAPIA <br />wEti SYSTEM WAIN El <br /> <br />0 iNsTANLAND44 <br />M <br />0 OuTop.sFERAcE WELL <br />INTENDED USE Tree of eakk <br />El INDUSINAL 0 OPEN RoTIOM <br />El DoESEI 111csysvATE 0 ORAvEl PAck/1312E <br />PUSUC/MUMCIPAL 0 oNvEN <br />0 SINGATION/A4 00,140,. <br />0 MoNITONNo <br />APPROX. DORN <br />0 I...STORMS TALL <br /> <br />0 OTHER <br />0 cRO Els CONNECT TIFFMA <br /> <br />0 YARN, Ex TRACTION WELL <br />DEPTH PUMP SET 33a FT. FIRST WATER LE0lEL,74) <br />OPUTTiCAC wELL • 0 sae eraruwo <br />GROUT SPIAAID HANG <br />tocRINO cereire 500/14T09E PIPE <br />TypE Of c•RMINTIFI/PvC <br />DEFT Fl OF oRTNTT SEAL <br />aNDLN SEAL Ana AILED 9Y <br />comeTRUCTioN •PECIFICAlloN• <br />1340.. OF wRi_ EXCAVATION DIA OF CONDUCTOR CASING <br />010. OF WELL CASINO <br />SPECIFICATION <br />0 OtiTTFRIctION, <br />oRnLIT SEAL puATRED: 0 V.4. 0 N. coNcRETE PEDESTAL SY DROLLER Y... 044* <br />reaeasto CONSTRUCTIONMISLURO miT1400 MUD NOTARY AIR FoollAJTY ALOOT CARL! oTHEN <br />I HEINOV CTRTIFy 111AT I HAVE FIREPARED THIS APPUCAtioN AND THAT 11.1E WORE WILL RE 00+4054 ACCOPOMRIF WITH IAN JOAOUIN COUNTY 01405IANcES. STATE LAWS, 0440 *4015 NM -77. <br />REGULATIONS OF THE SAN JOACITAIN COUNTY. HOME MANNA oR UCEHIED AGENT", IMMATURE CERTIFIES THE FOLLOWING, 'I CERTIFY THAT 114 THE PERICHNSANCE OF THE WONT FOR W4scH --- <br />TH. PERINI TO IMILNO, ISRAEL NOT EINLoY PENN*. ITUSJECT TO WORIMIAN'• coMpENSA nog LAWS OTC...FORMA. CONTRACTOR'S IsINNO DR •URCoI4TRACTI/40 SIGNATURE CERTIFIES <br />114E FOLLOWING: ' I CERTIFY THAT W4 Mt PERFORMANCE OF THE WONT Fork WEScH TH. EINAR IS ISSUFJ, I SHALL EMPLOY PERSONS IRNUECT TO NORIDAAJCS COANISNATION LAWS OF I. <br />CALW04VdA. TE40.UPtIC0AT MAI! CALL 24 MqSOS Dr ADVANCE PON ALL INOLINfry NANDECDOSIA A r /1451 4•044425. CoMPLETE ()DAWN° AT LOWER AMA PROVIDED a);:t <br />TIP. C i cJ c- <br />PLOT NAN 10.44 . 54041 <br />NAMES OF STREETS OFIP0ADS NIENTLIIT TO OM 50(14404040 1140 PROPERTY_ <br />2. ou'ruere OR THE PROPERTY. OSWSII ONSENSIONS AM) NORTH DIRECTION. <br />3, OIANNOIONED 01.17UNr• AND LOCATION Of ALL 110401N0 AND PROPOIND <br />STROCTUREs TACLIJOINO COVERED ANA, SUCH Al RATIOS, DINVENVAYII, AND 4045 11. <br /> <br />4. LOCATION OF MONK SEWAGE DISPOSAL 5(57010 00 TwOrCIIND <br />FIPANefoN OF IIENAOE DISPOSAL STIETETAI. <br />S. LOCATION OF WIRLa wITIEnd im.rso• or ONI HUNDRED FIFTY IT. <br />ON THE PRoPERTY OR ADJOINVICI rerarlyrry. <br />(,, II ___, <br />, i 2 <br />,54,, A At 17:e• <br />iv„ rti <br />:;.:.,"!..,:,, <br />oci If; 1998 <br />Osr..41 X <br />DERARTMENT UM ONLY <br />AppilestIon AcorrNI IT -1(5/ANOIJCA (i J-7(..'11A(4-() <br />arms kApAllI.. IIT <br />t e)N(q A.2—(6 <br />0*40 "fl.n.1.5441144, Sy_ 9.. 3 -- / 3 - <br />Onogriction Inownwition Oy <br />3RK02) 3_4 -zoo=> BR, <br />3, /3- 4Av) 4,64 EPD5- ft,c, — <br />A3 ft),, eel) 7b9Ioy <br />ACCOUNIFNO ONLY:AM/ rAc 4 <br />I., CODES VEINED AMOUNT 11040 0104 CHEW AsH Incovell •T DATE rEwANNERvICE RELUJOIT 444041*0 INVOICE <br />irtN° <br />Ci..;-V 15V 4 ( 0 4N49 149 0 10 /fie/q8 1:4 -7 gr-D-- <br />CY 00) <br />Pub Lisette Serv - Envie', 173 (1;97)