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100 vo;koczk kG <br />TYPI OF W01 <br />A <br />.❑.YA/HOU mwk ❑OFENSIA <br />OTTON D. OF WELL E}CAVATON 'JIA.OFCORARIGUCTORC ABO <br />�DOANGTICIMVATE ❑-I GRAVE. PACRout Of TYPE Or CASBMMTRL► oOf WELL CASWO O <br />❑ PMOCIMtURICPAI IJ OfFVFN OH4H OF GMUT SEAL SFECIFTCATON R <br />❑ 10#00ATIONIAG ❑OTHER OPO VT SM WSTALLED FY � OROVT SADA HAM! E <br />❑ MoNTomm _ ) � GROUT SEAL MMWf&.. ❑ Y. ❑ N. CORCIETE PIEDESTH n' pELLM O Y.I ❑N. a <br />AfPROR. OOT" LOCKMO CMSTER SDXMTOVE PSV $ <br />PROPOS® CONSTTNRi10NONSlLNO M[THOO; MVO ROTARY__ AIR ROTARY AVOfR__ CAME OTHER <br />1 W4[XV CFRII TTLAT t ITAW PREPAREO TWO AffLRCATION AND THAT TIE WOW HALL Be DONE N ACCOPOMYI WITH SAN JOAOWI COONTY OFOWANC 0. [TATE LAWS. ARD RILES AND <br />mou"DoNS Of I m SAN JOAOUIR COUNTY. HON! oWNFJt OR tJCEMEO AGENT•f SONATIRE C WWX. TME AOLLOWNO: 7 CfWWV THAT W THE PERFORA AWA OP TW WONT FOR v1HON <br />THIS PEMArt W ISSI[O, 1 e"ALL NOT ""PLOY PEPSINS MIS.IECT 113WOIEWAN'S COMPENSATION IAA@ Of CAAEFOESA COMNICTOR'S WENS M fUftONTMCiTPM SIGNATURE CERTfES �� <br />THE FMOWINO: M I CEIRS'Y THAT N TIM PEPPONAANCE OF THE WORK FON WHOH YAPS RETMIT W ISSILT, I ""ALL AlI.OV PERSONS SUBJECT TO WOIMOSAN'S CGMpERSATOR LAW. <br />CA!['dE•SA.' TIM AFIRICAM MLMY ALL" NDUIW w A/fVANCfFOR ALL IIhIUSW I!SJg)'PS,.e,TOJT,S AT M44"Ar->•I2l. COMPLETE OMVRIIG AT LOWER AREA �PLROVIUyfb. pp V <br />sl.a.P x JT.6- <br />--vim <br />HOT Pt" SP— 1.%a QSaw. 'ro <br />I- NAMES Of frREFTS OR ROADS NEAREST TO On TAIMORPG THE PPOP[RTY. 4. LOCATION OF HOUSE SEWAGE OWPDSAL VYREM OR N10IOSlD <br />E. OVRIIR or TLE PROPERTY, GNNG Don"NoNf ANO NORTH OWACTIoPc ERPANSON OF SEWAGE OWPOOAL LIYSTBAS. <br />]. WAENSOFED OVTUWN AND LOCATION OF RAE EIOBTWO AMO rEIOrono 1. Loc^A RI OF WELLS WTTISN RADKIS OF ONE W*MFXD FWT V FT. O <br />STMUCTW". SILZAIORIO COVOW ArtSIKH KH AS ►ATOS, OPPAWAYI, ANO E. WARON TIE Imom TY on ADJORRFRM PPKWW TY. <br />PAYMENT <br />PFCFfViFP <br />fi4AR ` 1999 <br />.. 'SA.q JOAQUIN CULWTT <br />AjBX HEALTH wAvKES <br />SWRCNAIEWTAL kEALTH Olmil"N. <br />AF...Nf­ A...H.Si <br />G.M Mwsi.n M <br />Owr.vY. 1.��Ho, <br />- L" C. L N <br />ACCOVATNO ONLY: I AtOI <br />17 COOPS I fTE INFO I MAGURT R <br />Pub HOHIM SON. - En m 173 (1/97) <br />ONLY <br />IACP <br />uN R[C4VTo SY ERT[ <br />P~TMBIVICE REOU[fT NLIAmoEI 1 N "Ol" <br />APPLICATION FOR WELLJPUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 488.3420 <br />110gmVIOIILE ►E1t o am$ 11EAI rI/M VAII Is"In <br />ma"I TE IN TF>Itlirow <br />APPAICATION W NTP[ NY MADE TO THE SAN <br />JOAORI COUNTY FOR A PERMIT TO CONIrtRIKT ANDA" INSTALL THE WOW OfOCI MED. TIM AP.RKATIM W MAGE N COMPUA14CE VRI11 MAN <br />JOAOL N COUNTY MMOPMENr T'-M4� CHAPTER 99-1111�6.A ANDTHE @TTAN'OAMS OE BAN JOAOUM COUNTY PUBLIC HEALD( @EnVWAf. ENVIRONMENTAL HEALTH OCVWION,. <br />JOB ADOMOSIOR APNP t�ff ,r-MA,E <br />Vm c,.lh'o—G.Q�n. P --j cK1' J w J PARCH. BUFJAT.O <br />OHMER'f MAME <br />AOpEBS �4P"^y'P _ PAON! + <br />cONrRAtTpil <br />� - tK►NS3�/LaIOMa�1��j��f <br />j,��SS.d..��,f�_ <br />Ao9rtef�f�f�Lltd: <br />wmCONTRACTOR -- - <br />_ — ADDRESS LICS^_ PHONE I <br />TYPE OF WELLEUm Q NEW waw. <br />❑ pffmACEMENT WELL ❑ MOMTORNO -Eu A ❑ OTHTR <br />❑ P*rALLATk w <br />❑ WELL IEpMR ❑ CfOfN'ONNECT SETARI ❑ VAMP EXTRACTION WWU E J <br />0 H.I. ❑ R.P.II <br />wyeTEM <br />it P. /t�- _ _ nwmw mwo, FT. FIRST WATCH O <br />I RYR OF fA1Ylry <br />�T— <br />❑ OVEOF-9ERVICE WELL 0 GEOMYSICAL WELL S ❑ SM SORNO e <br />TYPI OF W01 <br />A <br />.❑.YA/HOU mwk ❑OFENSIA <br />OTTON D. OF WELL E}CAVATON 'JIA.OFCORARIGUCTORC ABO <br />�DOANGTICIMVATE ❑-I GRAVE. PACRout Of TYPE Or CASBMMTRL► oOf WELL CASWO O <br />❑ PMOCIMtURICPAI IJ OfFVFN OH4H OF GMUT SEAL SFECIFTCATON R <br />❑ 10#00ATIONIAG ❑OTHER OPO VT SM WSTALLED FY � OROVT SADA HAM! E <br />❑ MoNTomm _ ) � GROUT SEAL MMWf&.. ❑ Y. ❑ N. CORCIETE PIEDESTH n' pELLM O Y.I ❑N. a <br />AfPROR. OOT" LOCKMO CMSTER SDXMTOVE PSV $ <br />PROPOS® CONSTTNRi10NONSlLNO M[THOO; MVO ROTARY__ AIR ROTARY AVOfR__ CAME OTHER <br />1 W4[XV CFRII TTLAT t ITAW PREPAREO TWO AffLRCATION AND THAT TIE WOW HALL Be DONE N ACCOPOMYI WITH SAN JOAOWI COONTY OFOWANC 0. [TATE LAWS. ARD RILES AND <br />mou"DoNS Of I m SAN JOAOUIR COUNTY. HON! oWNFJt OR tJCEMEO AGENT•f SONATIRE C WWX. TME AOLLOWNO: 7 CfWWV THAT W THE PERFORA AWA OP TW WONT FOR v1HON <br />THIS PEMArt W ISSI[O, 1 e"ALL NOT ""PLOY PEPSINS MIS.IECT 113WOIEWAN'S COMPENSATION IAA@ Of CAAEFOESA COMNICTOR'S WENS M fUftONTMCiTPM SIGNATURE CERTfES �� <br />THE FMOWINO: M I CEIRS'Y THAT N TIM PEPPONAANCE OF THE WORK FON WHOH YAPS RETMIT W ISSILT, I ""ALL AlI.OV PERSONS SUBJECT TO WOIMOSAN'S CGMpERSATOR LAW. <br />CA!['dE•SA.' TIM AFIRICAM MLMY ALL" NDUIW w A/fVANCfFOR ALL IIhIUSW I!SJg)'PS,.e,TOJT,S AT M44"Ar->•I2l. COMPLETE OMVRIIG AT LOWER AREA �PLROVIUyfb. pp V <br />sl.a.P x JT.6- <br />--vim <br />HOT Pt" SP— 1.%a QSaw. 'ro <br />I- NAMES Of frREFTS OR ROADS NEAREST TO On TAIMORPG THE PPOP[RTY. 4. LOCATION OF HOUSE SEWAGE OWPDSAL VYREM OR N10IOSlD <br />E. OVRIIR or TLE PROPERTY, GNNG Don"NoNf ANO NORTH OWACTIoPc ERPANSON OF SEWAGE OWPOOAL LIYSTBAS. <br />]. WAENSOFED OVTUWN AND LOCATION OF RAE EIOBTWO AMO rEIOrono 1. Loc^A RI OF WELLS WTTISN RADKIS OF ONE W*MFXD FWT V FT. O <br />STMUCTW". SILZAIORIO COVOW ArtSIKH KH AS ►ATOS, OPPAWAYI, ANO E. WARON TIE Imom TY on ADJORRFRM PPKWW TY. <br />PAYMENT <br />PFCFfViFP <br />fi4AR ` 1999 <br />.. 'SA.q JOAQUIN CULWTT <br />AjBX HEALTH wAvKES <br />SWRCNAIEWTAL kEALTH Olmil"N. <br />AF...Nf­ A...H.Si <br />G.M Mwsi.n M <br />Owr.vY. 1.��Ho, <br />- L" C. L N <br />ACCOVATNO ONLY: I AtOI <br />17 COOPS I fTE INFO I MAGURT R <br />Pub HOHIM SON. - En m 173 (1/97) <br />ONLY <br />IACP <br />uN R[C4VTo SY ERT[ <br />P~TMBIVICE REOU[fT NLIAmoEI 1 N "Ol" <br />