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" .PPLICATION FOR WELLfPUMP PERMIT r <br /> * � y JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> '�% ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAN JOAOUIN ST. STOCKTON,CA 86201-388 <br /> {209)488.3420 <br /> NOWNEFUNDARLI PERMrrP1B A I YEAH FROM <br /> AFftJCIrw1.EK i Tl%,r tw <br /> JOAQUIIN)ONco m HERE BY RLADE TO THE OAA JOAgIW COUNTY FOM A P'EIOIYT TO CONFTPSJCT ANOM wSTALL THE MOW DEMMED.THIS ANt1GTION M RIME IN COMPSIANCE WITH SAN <br /> JOAOUIN COUMY OEVFJAPPAflTT TITLL.CIIAPTpI 9-1116,3 ANb�TfjH,[({ifAFIO Of"M JO W COUNTY <br /> �KNILIIC}H�EA4.-rK OERMES.FMMUNELEMTAL HEALTH <br /> JOS ADOIIELiiOA ANY ltlLU45 ON �s 1 1 jwP W! I zttz' �•-•�G+��: . <br /> /� {� �r� [�� �PryM,CE^L LI�JAFNIS <br /> OWNER'S MALA •- M[V Gil sL�'0 .2z1.6�--35911 i <br /> ca+TFRtTOR I C-- 1 ADORE" _ E - ,S7�ucC' <br /> ruK CONrRAC7OR Ll.. A00 E +�F{ + ./ypNE• moi <br /> ]ffiE-OF WELLJ VMP. ❑NEW WELL ❑PSFLACEALENT WELL ❑mowrotwm WELL r ❑OTHER <br /> ❑INFrALLAT1ON ❑Yom rnmm wAm ❑CNOiFCONNECT PEPAIR ❑VAPDA omvzTEON WELL/ .1 i <br /> ❑Lr.i]Rwr <br /> IVF[of wMn M.P.HDFYM FUM/Wr--JT. FNWr WATER W.0 D <br /> ❑ovroF•aERVIc[wnL ❑'ammywAL wEu• �I[ wll roNAo r <br /> j <br /> N CONSTIIVCTION SPECIACATIOMe A <br /> ❑INWSTNAL ❑oNTI BOTTOM DI&OF WELL EXCAVATION DLA.OR CONDUCTOR CAS@16 O <br /> ❑OOMEETICMRVATE D GRAVEL PAOUSIUE TYPE OF CASINOJS7 EEl N DLA.OF WrU.CAMINO AD <br /> ❑FVYICAtUWCIPAL DEM LM'GROUT SEAL OPECIHCA I Ix <br /> Jf <br /> NIROA710WAo TIER GROUT SEAL YISTAUED DY GROUT IILAND NAME S <br /> MDNTDwIo `L L l�fY}:Zo N L- aRour @Ex FwY'ED:❑Y- N. cow-Rm FmEsrAL 6Y m&Lm,Ely- ❑N. a <br /> ANROi omM l.i—4'o � IDCKIPIa CHESTER SoxJSTOVE a. <br /> PROPOSED COMSTFUCTIOMJOILILUNG SSRKOD: LIDO NOTARY AAI ROTARY AUCiE11 CA �OTMo <br /> 1 NERE@Y CEMRY THAT I HAVE PREPARED Tl"""JCI,.AND THAT TM..WSL.DONE W ACCORDANCE MRTN■HI JOAOUIN COUNTY OROINANCM STATE LAWTL ARO RULES AHD III <br /> FEOULATIUNS OF THE LLW JOAOUW COLWrY.HOME OWNER OR 1104M AUNrO SAMNATURE CERrV4ES THE FOLLOWWO:'I CERTIFY THAT IN THE FERFORMLANCE OF THE VVQM FOR WISCM <br /> THIS FEF"T IS IUUIED,I GMALL NOT ELWWY PERSDNS MAJECTTO WORIOAAN'S COIAKUSAMON LAW@ OF CALIFOPSRA'CONTRACTONS HMY16 OR SUS-OON K%CTIW @IGNATi/lq CUITIHUS <br /> THE FO &tC14 PLFF`D AAMCE OF THE WORC FOIL NKIICM IS PERMIT IS ISWEb,i i1uLLl EIePLW►GRANS SWJECr Ta WORgeAM'S COMKASATION lAWIS OF <br /> TT• K HOURS W AO'VANC■FOR IISO :J W IlQ:TIONS AT 12SSI aSa.SaSS. COMHLTE d1AWS'Ib AT LOWER A11EA FRO <br /> +Tlo^r x <br /> KOT RAM�rav v fW.l SI.W •N <br /> 1.NAME@ OF @fFFETS OR FOADe NEAREef 70 OR eOUNOMM THE PROP[RTY. a. I.00ATIDM OF HOVE KEWA[IE OIWSK sYFTEY OR PRORO@Ep <br /> 2, OUTLINE OF THE PROPERTY.ONMJ6 DIMENOIONS AND MORIN OIRECT7614. EXPAMWN OF SEWAGE DIVOSAL @YWrVAS- i <br /> 3. OLMWEION[D OUTUNEK AND LOCATION 00 ALL MFTING NIG FROPOSED S.LOCATION OF WELLS WITHIN RAOU@ Of OUT HUNDRED FIFTY FT, <br /> FTRUCTVREe.INCLUI=COVERED AREAS KICK AN PATIO@.DNVEWAY@.ANO WALKS. ON TINE P'11OFSATY OR ADJOINMW PROPERTY. II <br /> �......:..........:.....s... .. .-- - - - - <br /> . ... .'....i.............. . . < . ....... - - - <br /> .:. ........_: .......: ...:. ... ... . .. - <br /> .... ....:....:....o . ;.. <br /> .:....d... _......;................. ..E......;...........,. . .. ...v.... : ...,.. > .. .........L.... _ <br /> .. .. v .,. ..',,. - b ...,. ..�,...... ... ...c.�.. <br /> : .. ..•....t...........:.........................- - .........: ...� <br /> .. n.. ...e.....�.. - <br /> ... ..... 4........, ..� .....:..., ... <br /> Ili .. '--. .' ...n... ....., ..,J. .r:..... : .....:i. -. ., <br /> _ .. . ... .... <br /> .4.... ..:, ......:....,,.:.... <br /> ......... .. .s. ....o.....:....t. <br /> DEPARTMENT USS ONLY <br /> .. ApPiNSO.n A...pN�S @T 17.E. Anr ' <br /> O�.ul kwl+Wn ST Ow. PI.R►L(.p.00.I1 SY D.LS ' <br /> i <br /> 71 <br /> OI.Vuall.n Lrw.alW.OT DSL. <br /> ACCOLAYTIMa ONLY: ALO/ FACT <br />` PE CODES FES INFO AMOUNT U&ITTm cKFyR1x ASN RLCEMM ST DATE IMI SISTABWICE REOVEST NU MS&L INVOICE <br /> r 1 <br /> r.. Q, <br /> i <br />