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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p4150 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NON-RU NOAILE►[ROUT 90RE3 1 YEAR FRORI GATE 1330ED <br /> ICm"Isd IN TrIrbu) <br /> AFFEICATION M IEA[NY MADE To THE IAN JDAOUIN COIMIY FOR A PENMR TO COHFTAU[T ANVAA"STALL TNT WOW DEGCFfWD.TIME APPLICAION IF MADE IN f.OMPUANCE MATH EAN <br /> JOAOUM COUNTY'1EV opMFM TITLE CHAPTER <br /> .� 9-1115,3 AMD THE,ITANDA,M.@/Of EAN JOAOUIN COUNTY FUNLC$MALT"01IMI11.'EINSOF�MXKTAL HEALTH VIAMON. <br /> JOB ADOSPBSOCNI#PHA 1O5 "5r /ynyie RA- CY '7 /ILVf PACELRF <br /> ~AllrN NME ADOMIS :y <br /> /p, <br /> w <br /> coNTNAcTon LWOY <br /> ` N'4`7 G'IJIJ�L�LJ T J4�6.j l(,(}Com_ ADLxEBB '�1 L!//l Ge_1 uc► .2�H+oNE F <br /> BUB CONTRACTOR 5TATq F• , ADORN UcE_ PHONE F <br /> nn ❑'""u. ❑IEPLAceMENT WEu ❑MoNRONNoWILLF ❑ot. <br /> ❑INSTALLATION ❑WELL SYSTEM MPAx,, LlCF10MCONNECT REPAIR ❑VAPOR tX1RACTION WELL F J <br /> R <br /> ❑M—❑ .P.M N.P. DEPTH RMSE <br /> P T FI. MST WATER LEVEL <br /> O <br /> rum" <br /> Of PUM <br /> ❑Otly F RVICE WELL ❑OEORIYIICAL YYELL f 10 EON So— <br /> ❑OEfTAICTAN' J <br /> GORfTRUCTION 4rfcyWAT10N4 A l <br /> ❑MAMNAL ❑ORM BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO <br /> ❑OOMtfTICNRVATE ❑oMVFL PAGXIBDE TYPE Of CASINCIMTEEIrPVC Alf+. <br /> CIA.OF WELL CASINO <br /> ❑PUBUCANIINCIPAL ❑MMN ^_ DEET"OF OIOUT NEAL L�F"i _ YECIMATION R <br /> ❑fffOATAN/AO ❑OTHER OIOUf STAL INSTALLED BY 11�-�N./�} OIOUT MAND NAME <br /> PUMPE� <br /> YOI+701�10 �/ ` oNOUT SEAL ED:ElLI <br /> Y— [OMCHTE HOESTAL 1Y OMELET❑Y. ❑N. !\ <br /> APFlIOX.DEPTH �J ` LOCRMO CMRLR NOXWTOVE TE <br /> PROPONW COMNTFMCTIONIDPRLRO MSTNOD:LRA NOTARY AIR NOTARY AU061_ CASTE <br /> I HE'EDV CERT¢Y THAT 111AVE PIEPAIMD TWO APPVCATION AND THAT TOE WOIK ML It DONE IN ACCOIOAW'E V"TH SAW JOAOUOI COUNTY DPONANCES.STATE LAM.AND NULES NNO/[' <br /> IEOULATIONS O THE SAN JOAOUW COUNTY.NOME OWNIR CSI LICMEED AGENT'S MHATUIE CERITHEE THE POLLOWBq''I CEIITIFY THAT IN THE PINOMAAWV M T f WORM FDII.( <br /> THIS HOAR 1E ISSUED,1/NULL NOT EMPLOY HRBOHI NINJMI TO WOP ASU"-6 COM AT/01V LAWS OF CAIN`oINBAL'CONTIUCTOTf H"W#G OR fUB{ONTNACTPM NANATUM CERIEME <br /> THE FOLLOWMS: 'I CERTSY THAT M THE KWOMLANC'E Of THE bVDM fpN W/SCII TMS PEOMT V IIIUlD.I SHALL EMPLOY HPVONO MJ[CT TO VMPKIAM'S COMPY/NATNII LAM OF <br /> CAixo MAL''%T,LN/J�N/A/,f/B/1-leOANT MI�N/T/{C/LA/µ?E�MOW NI AOVAMCI FOR ALL ILNOLOIBD INS/�P��:I.,RI,T,.M,f//NM Al11LM�SS-tE7l.COMRtT[o/11LWIN0 AT LOVYOI AMA►Ib <br /> NLv,w X ` •�"Y•�I YAilr't/ TMh VIED I�"� DN. �7/� �. <br /> PLOT nA104...I.fad"S—M I. Q <br /> 1.NA MIFI Of SREETN OR ROADS NURI <br /> HEfT TO OR NOIDBN THE N%opfRTY. P. LOCATION OF WVNE SEWAGE DNPONAL SYSTEM 011 PROPOSED / <br /> !.OTUNE OF THE PPD"RTY.OVINO DIM[NQONS AND NORTH DIMCTION_ EXPANSION Of SEWAOF DISPOSAL SYNTfUS, <br /> �.DNMMIOED 0IFTLIM6 AND LOCATION OF ALL EXISTING AND Fl10PON[D S.LOCATION OF WELLf WTRIIN RAdUB OF ONE W*4D SD MlY ff. <br /> BTRUCTWWf.BICLUVRM COVOW AREAE VJCH A.1 PATIOS,OMVEWAYI.AHD WALKS. = ON THE PIU/91tY ON ADJONMO PROP9ITY. <br /> ¢!ter <br /> 'OQMTMEMT INN ONLY <br /> A..k.Wn A..AI.f DT_ CJ , DN♦ A..`� <br /> dM MwPwNr.h D.I. IN—Ya. —or ON. <br /> I� C� <br /> ACCOIMITWO CWT, AAI FMl <br /> PT CODE$ PO INFO RANI-1 N6.NTTm CNa.—A.. RICB VlO MY DATE PEIM NOR INVOICE <br />