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./PLICATION- UMP PERI! <br /> SAN JJOOAAQUIN 4L111 ;YPUIHEALTH SES <br /> ENVIRONMENTAL HEAD DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)469-3420 <br /> �raa. et E: tTIAN FRKLAUdLI-4140 <br /> APNLICA Co N HENS EL MAW TO THE IAN JOAOUIN COUNTY FOR A PERIYIT To Co a AI la DMR CAU�VWm DeSC�.THIS JOAfTINRf COINfrY oEVELOPNEINT TITLE. 9-1 t 16.3 APIO APPLICATION N MAGE IN <br /> JOe ADDIESSMOR APNa E t STANDARDS OF SAN JOAOIAN COUNTY MMM HEALTH SERVICER DANCE WITH BAN <br /> h Ei�1V111DNMEi1TAt HEALTH p1VNppN. <br /> OWNER'S NAME QIKY t r k4 C O�(M,��QV1IL PARCEL EIZF1APNa�I 1 y <br /> CONTRACTOR 5vAtA-� (n�1 �C1L1 k 1� ADDRESS N �• � PHONE o �� <br /> SIIeCpINTRIyCTOR �'W wJ��11\ ,, 'F <br /> ADDRESS ..... J �1ca ,c,51 %1 <br /> ADDRESS r'd• GSC SI �� UCa nolo q <br /> m Rr�iTltdlt m ©NEW WELL O REPLACDPENT vau ❑monToram WELL 8- 0 OTHER <br /> )tNSTALLATION ❑WELL evsI EM REPAIR Q CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WNL <br /> r <br /> (TYPE OF Kw" IN.w©�� H P DEPTH PUMP SET FT. HIST WATEL LEVEL <br /> ©OUT•oFe>:NIVICE WELL I] OEOI*HYSRCAL WELL a .�S01L BORING <br /> 13DESTTI/CTION; a <br /> Typo mym <br /> ©1 INDUSTRIAL CI OPEN BOTTOM DIA.OF WELL EXCAVATION N DIA.OF CONDUCTOR CASMM <br /> D N a <br /> DwHEeTRCIPRIVATE D GRAVEL PAdUS12E TYPE OF CASMq/STEEUPM r� dA.OF WELL CASINO <br /> 13PiISLICA ILINICI'AL 13 o1SVEN DEPTH OF GROUT SEAL_.__ .7�. - _ SPECIFICATION a <br /> 13 Prommmawo <br /> oT GROUT SEAL SMAI I By GROUT DRAM)firNAME QfA} E <br /> MOwTOMD oROUT SEAL PUMPED: Y- I]Ns CO"cnErE PEDESTAL eY vmlml: 3 Yr s <br /> APPROX.DPTI LOCKING CNEST/E�SOXATTOVE PIPE s <br /> PROPOSED CON RLIOTI0RNDIILURIa METHOD!. MID ROTARY ASI BOTANY_ Y AUGER CABLE OTHEk_ <br /> 1 NEWSY CERTWY THAT I HAVE PREPARED THIS APPLICATION MID THAT THE WOISL WILL SE DONE IN ACCORDANCE VWTH SAN JOAOLM COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOACUIN Comm. Io"m OWNER OR LICENSED Ago"MMATU14E CERTIFIE/THE FOLLOWING:'1 CERTIFY THAT IN THE MWORI&ANCE OF THE Vmw FOR WHICH <br /> THIS MOM 1 N I ISUM,I SHALL NOT EMPLOY 1111MM SUaJECT TO wo11DMANPe 000AMMATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING ON MIS{ONTRACTING RWMTU E CE TFX@ <br /> THE FOLLOWINS: '1 CERTIFY THAT IN THE PERFOWANCE OF THE WOISL FOR WHICH THIS PEON IS Rg11E0.1 SHALL EMPLOY PERSONS SUBJECT TO W14-O ON COMPENSATION LAWS OF <br /> CALWOIIOA.' THE APPLICANT MINT CALL 24 HOURS If ADVANCE POR ALL RECURRED INSO TNWS AT 170e1440.94n. COMPLETE ORAVANG AT LOWER AREA PROVIDED. <br /> :u F O---AL6*7-- <br /> PLOT RAN prow to somal swgl -Ls <br /> 1. NALIES RIPTfEETe ON IIQAOS PRE/ 6T r0 oR aWNNOI4G THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> L SIM IEMEMIO 4010101011L opmE <br /> 5L~- wwala SALEFEIaP�ara S. LfIdAEIaN NIPnIaLa�EIIII 1wTLle M RMM <br /> TIM EEeE1@WAMWPL AI*#MMS. MIRTH PRIMP" SSMPWOV. D R1FTY FT. <br /> ...; ................. . ..;............ <br /> — -�. <br /> DEPART11IINT USE ONLT <br /> A}RSMMn AwPhe RNT DnS,�+� � L I Ar�r-�` <br /> dwe k�PaeNMLh Dia PLRnp MwP+eHla+eT DMS <br /> Dr+hutltr,IrrP�Hlw�fly `s two <br /> ACCOUNTING 4MV: mw FACS <br /> PE COO17S <br /> HE IF" AMONIIT PWWTED o"WoNIASH RECEIVED aT DATE PESHITNERIICE 11EOLNST NURYEEI HNvace <br /> Pub.Health ftv.-Emft.173(1197) <br />