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d4 19' 1J `� '5w 88 CH2)1 HILL Z003/003 <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> l N JOAOUIN COUNTY PUBLIC HEALTH SERVICES �� 3 <br /> P.O. EtOX ENVIRONMENTAL HEALTH DIVISION <br /> 388 304 EAsr MUM AVENUE. STOCKTON, CA 95Ml W <br /> &btfll,of C209) 48"20 <br /> �o el � NON•REFUIIRMIE PERMIT SMIFS 1 TEAL FI{0■PATE MSVFD ORIGINAL <br /> {c-I In TrYTRTrEEI <br /> ApRNCATiON 1 NFAE TO THE SAI JOAOUMN W LINTY fOR A PERLIIT TO CONSTRUCT ANOI INCYR,THE MW OESCRMEO.THIS APOLICATION w MADE IN COMRIANCE Wlrn EANIw�j(A,K <br /> "AQUA COo N MMO-gW MM CNAPTEII}1115.3 AND THE��STANDRACM or SAN JDADUA COUNTY POMC HEALTH SENVICEN. <br /> JOS ADMINNOR AP PAil �-G -�l 0 7 W. ENVMOTIMFMAL HEALTH wVISON. <br /> C CRY ^Tc�IG�-s,–, IARCEL SRFIA,ys <br /> OWNER'S NAME ..J ( 2rrn1 .DOME.. �o2S W l�e Lz{-1 <br /> pR G SHOW 0 <br /> AD Ra& -)uGy�ayNc,TA3T0 I,Dr pICN .�2D-OZf2 <br /> Sve cofTIOKTOR ,twt DIs�ru aYl LVlP_.ADd<ti Z� Vj6t V" OO,5i 2 G <br /> TYPE OP VFELLAOMr ❑ NM•WELL ❑ REPIAC(MENT MLL ❑ A9NROANG WELLPS <br /> ❑OTHER <br /> ❑ INSTALLATION ❑ WTii SYSTEM WMA ❑ CI9SSCOMIER PERAR ❑Soon EILTRACT9N vmL S <br /> ❑Nw❑II.p.1• N.P. <br /> IF VIE Of Minim OEPT/1N✓RT__Ff- FrVTWATERLEVEL O <br /> ❑ OVT-0F411vOE WF1L ❑ OEOPIO'pCN WELLS ❑ SOR SOTNO <br /> �DESTRINCFlDN: a bard QlY1 KP <br /> MTNWom NIR{ YR w wEu. cONSAUtTIOw <br /> MNaPEc.,DATIo_ <br /> I❑ DURIsµ ❑OPEN BOTTOM dA.OF WELL FXCI1VATbN IEIA OF CONDUCTOR CA®MB A <br /> U oowxrICIPIrvATE 11CmAm PACKIRF D <br /> ❑ <br /> TYPE Of CASINGIFTEOUN CIA-CIA-Of WELL CASINO 0 pNr1ICANUMCNAI 13DISVEN DEPTH Or owSEAL e4ECIFCATION <br /> ❑ IRR9ATIDN/AO ❑DTNER GROUT SEµ,MSY L wA <br /> O MormoR.e oroR rRENp NAME E <br /> OPIpUT SEAL Ntowv :13 Y. ❑N. CONCfWIl PEbtSTALeYwEUER❑Y. ON. y <br /> RONSON-0111714 LOWNRO CHES SOIIROVE PAE <br /> 5 <br /> MOSCOWCONSTIIUCTIOwNpRRUwO MRl9p: MUD ROTAIG' AM POTAw AUGER CASLL OTMERL <br /> N NEAESY CERTIFY'THAT 1 NAVEUM,CO,,,,,.PRNTIME APROCATMMµ0 TMAi THF WDRR V/ILL lE DONE MN ACCORDANCE WITH tµAAWMI W 11/IlY OI9IMAMCES.RATE AMD ,,,g AND <br /> REWLA710NS OL THE CµJOwOUMN COVNOME OWNEp OR UMIRD AGENT'S SIOMATNR cfwrp E11 TME r0{ wwo:-1 CERY NT'THAT M THE PEIIOMNANGE OF TME WOOL NOR YEHICH <br /> TWO PFIOAR w ISrM,I SHALL NOT FMPLOY RANCH"SUWECT TO WORNA SITS COEEABwRTION UM Of CAILAWP A' CONTRACTOR'S NWV OR SUGCONTRACTGq wON11TLM CEITITEC <br /> THF EOLLOWwq: 'I CERTIFY THAT IN TME RN"FAUWCF OF THE WOK WR WNICM NNIS R/rA7T A RN IED,1 SHAY ENI PE/wONs S11eJR'T TO SHIONN M'S ObMP6NAT9M LAM Or <br /> CALAORNIA APRT IQ MUNI C W MOW MI AbYAMCE TOR RLL RE aRa,NN,,NCC/)}fq� AT MOST .}Ea. PG7NRyTE DM\YIHO AT LOW411 ARFA ITpy/amomm 4 <br /> TIMs <br /> IfOT PUN IPwr w 11W.1 4P1. •t. <br /> t. NAM(S <br /> Of ST IXTS OR a HEAR9T'TO OR eODHDDRO THE M9pERTY. 4. H)CATION OF NOM Sk1YAOE VM M SYSTEM OR TOFpeED <br /> E. OUTIINF OF THE PROPERTY,9ND9 DIMENe9H6 AND NORTH PlAl!"ON. O AWO N OF RWAftt DwROSAi SySTETAE. <br /> E. DSAIIIIII O 01114NIS AMP LOCATION OP ALL EX,,,,, N,pNOR I S. WCAMN Or•n'EIIN)WR1RN RAd W or ONE MUHCOM rRT,R. <br /> RR11C lINSC,MNCLUDINO COVERED AREAS SUCH AS PATIUS,ORI VEWAYS.AND WAUIS, ON THE PROSI OR ADJOWINO PROpF/1TY. <br /> DNARTMpIT WE ONLY <br /> wIb1N.A....1 eT 0� <br /> D.0 L Z <br /> M bwp.11Nm er Ou.oz <br /> PVny wp.Mn eT oy. <br /> .n.u.11.n NwPA.1a.•er T 0.N. <br /> ACC0INNTWO ONLY: ADP FI1CP <br /> PE COOP NEE L•RO ANAOUNT PPAITTm Cmac RTRYM MY DATE Q PI/EMTwDMCE AEGYNT wwASP IMVVICE <br /> =02- <br /> 40/z% 0 <br />