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5!w/ APPLICATION FOR WELLlPUMP PERMITN—'' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 POR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IC9Mpblt M TdpRettel APPLICATION 19 OfFRE BY MADE TO THE RAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORT DESCRIBED.71011 AMICATION 19 MADE IN COMPLIANCE WRIT SAN JOAOVIN COUNTY oEVELOr111ENT'RLE.CIIAPTER 9.1116.3 AND THE STANDARD$Of RAN JOAOUM COUNTY PUBLIC HfALTII SERVICES,FMIRONMEMAL HEALTH DMRION. JOB ADDRESRATR APHO (/O'3 S • �i�Co\yI JI F-^' cRY r. L ��LL to �y(..0 •! MQ�I r`« / rrARCFI RIZFIAMJF •� Q OWMEA'N NAME / f'-, M%2N p i h ADDRESS -Z0 3 %- I-LtiIW i lli S4-4-11.r' $2 3–S�'L3 /L A 1 � !IOM CONT"ACTOR ATL g1A.)SC&% —s `V-L. ADFMAII D O (sw (�L'c/�s Ar. LICE p �JRaNEF 5'"—tZ?-�I SVN CONTRACTOR �1!� b Ort,,Ld '✓�. ADOMRS'•O•&X SI PCS lSk LICE�7�i�-E proNE#-k-;-31'x^4V IS TYPE OF wELI/PUMA ❑HEw wett ❑RErI.ACEMEM WELL ❑Mowfora o WELL► ❑OTHER ❑INRTAMATION ❑WELL SYSTEM AFFAIR ❑C110e9-CONMCT REPAIR ❑VAPOR E%'"ACTION WELL I J 11NNP11 R,PN. N.P. DErTH RMP SET R. 1111117 WATER tawl. 0 IT We OF RVMPI — ❑OVT-or-SERVICE WELL ❑DLEORIYSICAL WA1(E/LL.ol ❑ ROIL BORING N �OESTRI/CTION: V'Yos7 0�. �0 �' 1Mt�` TCl .SV/�`*V'- NT-DED Vf "OFwm CONSTRI/C110N /ECIFIC ION eIx A ❑INOUSTRIAL ❑OPEN BOTTOM DIA.OF WELL txCAVATION301A.of CONDUCTOR CARING -! O 11DOMERIICAriVATE (3ORAVFL rACKMIZE_ TYI'f Or CARIIMIIIIITTIA•VC F)YV(, dA.Or WFI.L CASINO 417 0 ❑FVMCMUPMWAL ❑DRIVEN DEPT$#OF ORo1FT REAL 30 t14CIfICATION SC 140 R ❑M"ATION/AO ❑OTHER (ROOM REAL*M A11M BY Fy�L L• IL OROUt BRAND NAME E 11MOMTOISNO OROUr REAL PUMPED:ty Yr [IN. CONCWtl!PEDESTAL BY DF%RllA:❑YM ❑NA S APPROX.Dt"ll LOCKING CHESTER 11O11/RTOVE MIT y. PRO►ONfD CONNt11UCNONIDPL11N0 MRNOD:MUD ROTARY AIR ROTARY AUGER CA11LE OTHER k— I IN'RENY CERTIFY T14AT I HAVE PREPARED TIIR AIItICAt10N AM THAT 111E WORK WILL NE DONE Of ACCORDANCE WIRII SAN JOAOUIN COUNTY ORIMANCES,tTAlf LAWN,AND BORES AND IEOURATIONS OF THE SAN JOAOIIN COUNTY,HOME OWNER OR LICENSED AOENT'f t10NATUM CF.R?Wftf THE F(LLOWMO:'1 CERTIFY THATIN THE PERFORMANCE OF TIK WORK FOR WHICII TIIR rERAR 19 R RNR).1 SIIALL NOT EMPLOY PERSON!SUBJECT TO WORKMANS'S COMPENSATION LAWN OF CALIFORNIA.'CONTRACTOR' IIRNO OR MR-COPfRARE CTPM MNATVCERTFIEt T1IFFOLLOVAN(1: 'I CERTIFY THAT M THE PERFORMANCE OF THE WOW FOR WWII TRt PERMIT IN ISSUED,1/HALL EMPLOY PERSONS SUBJECT TO WORN MAN'/COMPO19AT1ON LAWN OF CALIFORNIA.* THIO APPLMANT MUST CALL 24 NOW IN ADVANCII FOR ALL PTOL"M"HoPlICT10NS AT 1lS0I /4p-/r 1�4"..COMRITE DMWINO AT(OWER AREA PMOVW". M KFX t.3(.(l/ •L/� TISt RAilJI'1.� E A/A/- DHr O,Rg PLOT PIAN M.-1e S.W.)11eNA 'is 1.NAMER OF STREET9 OR ROADS NEAREST TO OR NOUNDOM THE PROTERfY. 4.LOCATION OF HOUSE SEWAGE OISPVtAt SYSTEM on PIDFORED !.OUT11E0E of TIRE PROPERTY,OIVNq DIMEN910119 AND NORTH DIRECTION. EXPANSION OF SEWAGE INSPOSAL SYSTEMS. 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXBOTIRG AND MIDPOOFO S.LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Ff. NTIIVCTUIRES,INCLUDING COVERED AREAS PLICA AN rATION,DRfVEWAY11,AND WALKS. ON THE P1OPEMY OR All"I NNO PROPERTY, _-- 177x15 tl I().11 111 r w Q q a z ro & ZW30 �Ll i g�L�Ja o0 0-tr 2 V w Of V P � O a O Z ~1- n a a Z O i I.J, .. �Il10llgq 7�'tlN015 � � iI � � Ajlltl Y ,X k' aE ❑ ® n L Yt OPS606 xlgwrTr --3T'- amen DEPARTMENT Volt ONLY AFFRRrrlbn A-W.A By /- 1 �7,! - /1 Do. { A- • �� I.eMI#--it-By O�$# AxnP InxPbSen Az H� Dnxlnxelirn Mwl.Mbn 11Y Cxmm.nl,: ACCOUNTING ONLY: AUDI FACT ►E COOL I FEE INTO AMOUNT REMITTED ClIt"01CA411 RECEIVED SY DATE F9IME111!VICE MoUIEST NUMt9R INVOICE Asa d (�S Dish Pub Neahh Serv.-E1W1ro.173(1/97)