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VV� APPLICATION FOR WELL/PUMP PERMIT <br /> SAN J <br /> OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WESER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> KOK REFUNDKILE PERMIT EXPIRES 1 YEAR FA6M DATE ISSUED <br /> IGISPISR M Tr41ketEI <br /> APPUCAMN IR IRrE BY MADE TO THE BAN JOAODUI COUNTY FOR A PEIMSI TO CONSTRUCT ANORIR INSTALL THE WOR[DESCRIBED-7N18 APPOCAFION 19 MADE W COMPLIANCE WIT 11 SAN <br /> JUADSN COUNTY DEVELOPMENT in LE.CHAPTERR 9 1L115..3/ANO THE STA(NNDAEEJS Of BAN JOAOVIN COUNTY PVRUC HEAALLTTH SERVICER,ENVIRONMENTAL HEALTH MVISTON, <br /> JOB ADORBE.OR ADfId r��i�.�d n7 1, W b ij "? • �(' �H CITY l !O rAL,h,CEl 81ZFlAPNI <br /> OWNER HAMe._��Ftt d AfS C.I� ADIIREESSe P-ow,a <br /> CONTRACTOR <br /> �G ,,, n �S 1�Y�L:'1 C�+_ ADE.RESE +�� �)Lt/,`y- / r Elc►G 3 -�3�PHONE► �6-yr� <br /> SLA CONTMACTOR ADOIFSS A!i`7 <br /> UC►� A1oFR► <br /> TYPE OF WELIJPUMP, ❑NEW WELL ❑IERACFM*NT WELL ❑MOHO OMA WELL I ❑OTHER- <br /> 13 <br /> THE — <br /> ❑TNFI1AR-LTLATX� ❑WELL SYST EIA REPAIR r�LJ CMOSSLONNECT REPAIR ❑VAPc"EX7 RACTION WALL ISt" J <br /> ❑N..+Lj Re.lr H.P, UFr N RNP-dju-FT. FIRST WATER LEVEL %may A 0 <br /> I7YPE Or PV RAFI <br /> ❑OUT OF-STRVICE WELL ❑GFOPHYSICAL WFI-L 0 ❑ ROS.W."O S <br /> l.J DESTRUCTION: <br /> ni Us rrrE W N+TRIC?ION SrEC CA IONS A <br /> ❑*WSTRAL ❑OPEN BOTTOM ORA.Of WELL EXCAVATION JRA.OF CONUVCTOR CASING 0 <br /> �❑E OOMESTICA.IVVATF ❑ PI <br /> DAVEL PA .ntfZF TYrF OF CASMMIj.TFE1/P 1C DIA.OF WELL CASINO O <br /> U IVRUCNUMCIPAL ❑ORVER uErTH OF GRouT SEN. _ W FRCAT%`H R <br /> �T <br /> lJ R.pAiION/AG OTHER DIGITI REAL INSTALLED SY GROUT eMIA NAME E <br /> ❑MOW70FINO OROUT SFAL Pi1HMEO:❑Y� ❑N. CONCRETE PEOEITAL SV OI IM-❑YRR ❑N. 3 <br /> A►R10S.OOT" LOCKING CIFSTER NOFAIOVE APE 5 <br /> PROPO/EA COMSTRUCTfOR101ILUN0 MEENOP. MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER <br /> I HE.EBV CEIITIFY THAT I I IAV*PREPARED TMS ADPLICAT"ANO THAT THE WORK WALL BE DONE tN ACCORDANA MATN IAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> RFOVLATIONS OF THE SU <br /> AN AAON COUNTY.HOW ORARIUL OR IG <br /> UCERRO AGENT'S SIGNATURE CERIFI S THE POLLOWINO!'I CERTIFY THAT III THE PERFORMANCE OF TIRE O(WOFOR <br /> MARC" <br /> THIS PERMIT 18 ISSUED,1 SHALL HOT EASR OY PER/ONe SUBJECT TO WORKMAN a COIANNFATIOM LAWN OF CAAFOIFMA.'CONTRACTOR'S I"PING OR SUSCON1vwT1NA MNATURE CERTIFIES <br /> THE FOLLOW 40: 'I CWIFY 714AT IN PK PERFORMANCE OF TN WORK ION WHICH TNI PERMIT IS IISIRLTJ.I SHALL EMPLOY PERSONS SUBJECT TO MORIWARY COMPgISAT10N LAWS OF <br /> C AUFORMA.' Y cILM IAT IN IEbMANCE FOR ALL Rff, RA0D1EKS►SCTMNS AT 12WI ASS-23.COMPLEKL OMRMNO AT lOW[EL AREA Fw/OVIDEb. Jam/ <br /> S*-I X cI L T1M. 6 !4-tV-e/ <br /> j PLOT FLAN rO`—N".1 S"I. I. <br /> O <br /> 1,NAMES OF STREETS OR MOAOS NEAREST TO OM SOUNDING THF PPERPfRTY. 4. LOCATION OF HOUSE SEWAOE(XIPUSAL SYSTEM OR AWrloofD <br /> i. <br /> mum OF THE HRORr~RrY,ODAEEHSIONS AND NORTH DIRECTION- EX►A&SMH OP SEWAGE DISPOSAL SYSTEMS, ry <br /> ].OIMFNSIONEO M"L)WS AND LOCATION OF ALL lXIST1N0 AND PPOP OSED S.LOCATION OP WfILS WRFTMN MAOMIS OF ONE NUNOp[D FIFTY R. <br /> STACFIMES.NCLUOINO COVERED AREAS SUCH AS►ATOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINIM PICfERETY. On <br /> y <br /> :.. • .' AAAA... � <br /> i <br /> G AAAA. .• ;AAAA. i s <br /> 'O <br /> 1 <br /> JAN 61999 <br /> 3A.,Jp•.I}Lrk nR:I.RdIY <br /> FUN-l1C NTAt.TF;SEr'iVICC: <br /> n ., ^=NVIR(;NMENTAI.NFj;CJ-I <br /> R <br /> �•. C..... .,AAAA. AAAA. .._ _...... .. ....._ __AAAA._ .:. <br /> DITAMrT.RIFIT Use ONLY <br /> D N A•r���p <br /> A.r..InF..etl.n Sr a,. <br /> o......w� L..eE D.I. <br /> CM... <br /> I <br /> ACCOIAI LIMO OMIT: ATO/ FAC/ � <br /> FE*NO AMOUNT"PATIO) CIA." RCDAY DAE FSIFAITA111.4"MO01M)T 1►UNS1 OCh -6y -770(7) -� _ <br /> Pub 4eaM Serv.•EPrviro.173 11197) <br />