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vlv <br /> r3' _5 2- <br /> APPLICATION FOR WLIC HEA PERMIT Wow d <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION P L� Ac f , <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202— <br /> (209) <br /> 520(209) 468-3420 <br /> NON.REFUNOABLE PERMIT EXPIRES I YEAR FROM GATE ISSUED <br /> (CumPlttt IR Irlplkattl MADE <br /> NSTALL THE WORK OESCMSFD <br /> ICAMN 18 <br /> A OLIN MM 19 HERE <br /> DEVELOPMENT THE <br /> E.SAN <br /> JOA <br /> B1f 171 S AND THE STANDARDS Of SAN MAWIN CIOUNfV PI/BLIC HEALTH 6ERNCEe�IEHMAUNMENTAL HEALTH IDMBION.IANCE YRfll SAN <br /> U L, <br /> LCITY CTC'l !- PARCEL 912VAPNI <br /> ,`!i 1�•cL—�- w`• // AOOREBeJOR AODR99NR APNI <br /> OWNER'S NAME-57bVC )5/Ze6 /O —, 7-77 <br /> .. L l: M; . •�1 I Y�RroNE/ 1�T 5 <br /> _ ADDRESS y ``' <br /> P bNE <br /> ApdEee <br /> RM CONTRACTOR _ """�0 �•[ <br /> y` d MONGOPoHG WELL, OTHER`� ❑ <br /> TYPE OF WELVPUMP: ❑ NEW WELL ❑ REPUCEMENT WELL ❑ VAPOn EXTSJCTK)N WELL I J <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRDSALONNECT REPAID FIRST WATER IEVK O <br /> ❑New❑R.s.K H.P. OOEM"PUMP SET�FT. f.I <br /> ❑ OORv61CAl WLL F l7 OIL SONNO <br /> 1POF MMPI ❑ OUT,D "RE WELL <br /> ❑DESTRUCTION: A <br /> TYPE OF WELL <br /> CO SPECUICATIONS 1 ��J•-L- D <br /> IMi[NDED UEE VA.OF CONDUCTOR CASINO <br /> ❑OPEN 90TTOM DIA.Of WELL EXCAVATION GM.OF WELL CASINO� O <br /> IMU❑ DDM*STIC Tr-�O1 L x Z TYPE Of CASINGMTEEIIP/C P Y L'� <br /> ❑ OOME9TICAKNVATE tyIOMVK PAC%1812E �"�"^ SPECIFICATION ?vl- <br /> DEPTH Of GROAT SEAL <br /> ❑ PUSVCIMUNIOIPAL DRIVER �..ly OROUT BRAND NAME �G''11. E <br /> OPDVT SEAL INSTA <br /> C3 IRRIOATMNIAO Cl OTHER llEO 9Y <br /> OROVT SEAL PVMFED: HYr ❑Ns CONCRETE PEDESTAL BY DPol1ER:❑Yr ®Ne S <br /> fT 5 <br /> Q MONHOPoNQ LOC%IND CHESTER e0%/STOVE PIPE- <br /> APPROX.OEM" AW AVOER 11 CAmE OTHER <br /> wLOrotm CONtTRVCTIONIDPoWND MET1100: MVD ROTARY AIR ROTARY A RULES AND <br /> WHS 1 CENfIFY THAT W THE PERFORMANCE Of TIRE WORK FOR WHICH <br /> REQI1lATIOHe Of THE SAN JDAOVRI COUNTYBTj MOME AO TM N OR AN THAT T WORK ILL BE RE IN ACES TIIF WLLO.: �AYN COUNTY OnDI WDRM.STATE UWS. <br /> TRIO PERMR 1919SVED.I SHALL NOT DMKOY PERSONS SUBJECT Tp WORKMAN't COMPE2NATION LAWS OF CALIFOFtSA• CONTRACTOR'S HIPoNO OTO WoSR AS-g OMIRSI ATIO CERTIFIES <br /> THIS <br /> THE I1LP CEW'FY CALL M""SUAME OF TIRE WORK MR <br /> NOW IM ADV ANC!FOR ALL R WHICH THIS <br /> SP""A"T IAT 1]0SI J�.tf.�MMpWEE RAW M AT LO AREA fROC�D' SAt10M LAWS OF <br /> C f�,.� f—7i T11N <br /> SIO.� It <br /> KOT MN ID..w I.9.0.1 Ba.l. '[s <br /> t. IDEATION OF HOUSE SEWAGE d9FOSAL SYSTEM OR mLoro <br /> SM <br /> EXPANmUN OF SEWAOE MSPOSAIL SYSTEMS. <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SAM NOR THE K CM"' . S. LOCATION OF WELLS WRIRN RAORtt IMF ONE HUNORIM FIFTY FT. <br /> 2. OVTLNE OF THE PROPERTY.annOS dMENS10OUTLINES NS AND NORTH dRECTION. THE ppppERTY OR AOJOmIIIO PROPERTY' <br /> T.STm1CNmmo TURE0.SICLUO M COVERED AREAS SIICMLOCATURN OF AUL EAS PPATIIO DRIVEWRI AM AYS,NA WN S. _ <br /> UEPARTMBIT USE ONLY <br /> Ag6a.lbn A.agIM eF �• / / <br /> Al <br /> awA...Orll.n er on. PIm.In.Pstlen er oH. <br /> o.. <br /> n.wns[w.I...slbn er <br /> ACCOUNTING ORLY: AIDS FACI <br /> PE COO" FEE INFO AMOUNT REMITTED HECK ASH RECEIVED BY DATE P9SUITItF1MCE REQUEST NUMBER INVOICE <br /> t O' D <br /> l I <br />