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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)48&3420 <br /> RON REFUNDABLE PERMIT EXPIM 1 YEAR FROM DATE 13SUEQ <br /> r4mv Ste I9 1PIPIh9114 <br /> AI'MICAt KIN FA MAP!BY MAD!TO IME BAN JOAL COVNTY FOM A PIMMI TO CONTTMICT ANDOM IN67ML TPIE WOPR Of ICNRFD.71119 APPLICATION 19 MADE IN COMB IANCF IMII SAN <br /> JOAOUIN COLO O(VTLOFWFNT TITLE,CHAPTER S I I 15AAM THE STANC11 DF AN JOA011R1 CO MV RINK IIEALTII E_urvI110EE,ENVRlN"NIAL HEALTH IYAMON. <br /> JOs AOOR(ssA7M AM, �. f.1TY (l I ! • PAPICFL.1111AP1I <br /> COMPACTOR.VAL��/n ADOM99 <br /> ISI 1X.. P' /•IC 1I /`/ AFNIIIF/E LIC 1 'v F1/0—.' <br /> RIA CO MACTOR ADUMt/E CICS PFOHEI <br /> TYPE OP WtltjVUTAP. ❑NFW WEU. ❑AIMACEMENI WELL ❑MONOONNO WELLI ❑11 OTHER_ <br /> ❑INSTALLATON [I WELL/YSTFM REPAIR ❑CMOSS- CNWCT REPAIR 0 VAMM UTMCTR)N WELL P J <br /> to h ❑ 11 P 3 _ OEMM RUMP/ET_F7 fFR--1,R tEVFL O <br /> M YPE OF PUPAPI <br /> /1j (_-ar{VTDF RM/yJ1C[WELL{(J') /y7❑OEORIr SICAL w[Iu f ❑ sat sa NN6 ��{�-// )J ��\ S <br /> D(NTRMTION- A — -,A:" ,SAI, A> 3 L 11 _/'•K�l/.LJ <br /> INTSNOEO USE rm OF WEEL CONS rRVCIION IFlCA p1Ff A <br /> 119IDUs110At ❑ORN BOTTOM OVA.OF WELL EXCAVATION rAA.OF CONDUCTOR[A11910 0 <br /> ❑DOAII811CAVOVAT[ ❑ORAWL PACKMZF_ TYPE OF CARNOMTEFI..'VC dA,OF WILL CA61W 0 <br /> ❑R ,1NIUWCIPAt ❑amm" DEPTtl OF Gq SEAL _ SPECIFICATON R <br /> ❑MOI10AIIONVAO 13 OTHER OROVT SEAL INSTALLED BY _ ORDVt 9RMO NAMF E <br /> 0MOMTOM1MO GROAT MAL MMRO-❑Y— ❑F1• CONCRETIPIDESTAL■YORRIIR;❑— ❑R1s 5 <br /> AP Y.DPf1M IOCt(Dp C--t"SOXF Ovf I4F S <br /> PR RW COM8TIHICT1OMMR1tUNO M"MCWr ARA MTAT' AM ROTARY AVO(R CAME 07HEM <br /> I MrVNY CE ATIF`/tMAF 1 FIAVE PREPARED THIS M4lICATON ANO THAT 7M WOMK WRL SE DONE M ACCOROA A WITH SAN JOAOLW4 COUNTY OIOIP ANCES.STATE LAWS.AND RULES AW <br /> PEDIRA-11 OF THI 9AM JOAOIIM CdUNTY. HOME OWNER OR UCINI EV AGENT'S SIONAT VW CERT F*41714'GUOWIFO:'I CMFY IHAT M THE rFRfOnMAJPCE OF ME WoM FOR WHICH <br /> THIS MAPAIT IS 1SSUEO,IN#Ali W T tMKL PFPtMONS SUBJECT 70 WOMMAM'0 CO—EPIIATION LAWS OF CA.FOMMA.'COM RACTOM'91SFEIO OR"1 CONTRAC T FO SOMATLRE CERT FRS <br /> TNF PO W '1 CERTFY TNAI N TM PEIWAMANC[OR T/R NO/1f F01�WMFCII TMt RIOAR 1/I//LUED.I HALL IrOY rtRSON9 SU9.JFCT TO WORgRA11's C011Pf1MAT LAWS OF <br /> CALM A. 711E CAI MLI9T CA 110 S IM ADVANCE ALL RE TAlRVO TO1H A.�C�IRS iIH.COMPIlT!OIUWRIO AT LOWF11 MEA PEID O. <br /> PP..1 TI.• O.1• <br /> UPLOT P1A11 IDrPw t.M•I•I 9•.F. <br /> 1 NAMF■OF STFF[TS(VR ROADS WAPFST TO OR—k—)+o THE PROPERTY. 1. ATOM Of NOOSE 9TWA.p9fOSAA SYSTEM OR MgrOsto <br /> E.OUTLIR Of TIVF PPIOPCPW.OP~DFAM ONs AND MONTH CNAICIOW EXPANSOM Or S[WAOS Olwo 1 sYSTEAIs. <br /> D.DV N/UWD OVILIHF9 ANO LOCATION OF ALL IXWr*0 AMO PRDg140 •.LOCATION Of MLLS MRTMN RAORl/OF OM HU.DMD FlF FT, <br /> STRIICTUIES,MCLUOIMO COVERED AREA$WCH As PATOS.DRWITWAY9.ANO WALK 1. OH THE PROPERTY OM ADJOMINO P WMATY. <br /> (. I.NS�E eT�D NOT <br /> N S191JEb <br /> -V <br /> AUG 31 <br /> PU•a1C•fERLTh SER4ICR-S <br /> t :JIHGHF.1cN.Ai.HF..ALTh OIVIbIUI� <br /> / DOARrnFdT VIV ONLY <br /> A.PSPw1«.A•••0 .._ O•V• 3 Aw <br /> 0—Moes,—Er D•V• AmP MM•VIFn 1T 'MF• <br /> ACCOVAIMOOMLY! AOI I-CI IIT' <br /> R CODES F111— M LINT REMTT[D HECK MASN RICEIVM 11Y DAT[ t1101VIC(REOUE9T —DICE II <br /> �� ! '� L.[ IIY11 <br /> Pub Health S—-Envoo.173 11;97) <br />