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<br />sAii alums cOUNTY PUBIJC HEALTH SERVICES
<br />ENVIRONMENTAL HEALTH DIVISION 6() P.C. SOX 304 EAST Weial AVENUE -STOCKTON, CA-sszol 7388 insi 48114420
<br />laill-REFUNIOANIE PFilliff FXPW't ! Y.gi!! MIS! !MITE MUM',
<br />figitigiiiiMERM PPLICATION ni Him gy MADE TO THE SAN JOAQUIN COMITY FOR A PEMATT TO CONSTRUCT ANIIVOR INSTALL THE WO( DESCRA. TEM MIN...!CATIONIS MACE = =MPLOASCE WITH SAN ',AWN COUNTYr...1r.fga,. cr.,.ez.•,:r Tm.,.t. C."-.1.APTM9-111.7...Z ,o,rz -;;', z:-..-.4:F.w.arxi OF Ny4 JOAGUIN COUNTY PUISOC HEALTH SERVICES. Erwwematerrm. Kerrie conneww.
<br />oe Adepaessoa AFTM 7 0 -17 Pc.c.;S-i- c Au ei ,uu 9- =,-., .,ST O c_.K_ TO A) num."73... amicialiAiiii /6 ,2 So <Pt "
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<br />oh-m.4- Toliwcks-r-e,...) s-r rc-IC, ,_;-•-•to 160-4.:71 ,--"15' iv C. • Apopian T. os 3,.,.. ),Z,,..; siz:„..31Z...(1, s.,... 5 1 ur.. n::727 4 S' ...qopiE • @ /4) 3 73 -II I f US CONTRACTOR
<br /> ADDRES8 Lacs mom*
<br />YPE OF WELL/PUMP: Umew writ_
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<br />0 NEU. erwroA REPARS
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<br />DEPTH PURW SET FT.
<br />SEOPHYSICAL WELL •
<br />ca VAPOR EXTRACTION WIC.L
<br />FEIST WATER L.f.'.11L
<br />C SOIL BORING
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<br />YPF OF Pump)
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<br />0 OIST-0E-Selv/c2 WELL
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<br />g J DENTRUCTION,
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<br />CoNSTRIJCTIOR SPECIRCATIOM
<br />DIA. Of WH.1. EXCAVATION
<br />TYPE Of agamorsnmurvc IVC 1`T'Pe0 MA. Of WELL CASING 2 .‘
<br />,smcwor•Anorf DEPTH OF GROUT SEAL,
<br /> NSTASI.E0 SY 31- foam Immo NAN,. C.A...aycr
<br />SEAL ?WASTE); arm 'CAN CONCRETE PEDESTAL BY I:ISSUE% 1.-.1 `its
<br />CAED:M SOX/Zit:AT APE
<br />aPOSID (XIIIISTIRUCROMORILL/NO METHOD N/0 ROTARY AIR ROTARY CAM: CM-ES
<br />WRIST CEPIT/FY THAT 3HAHE PREpARED nee AFFIXATION ANC THAT THE WORK WEL Ef OCHE M 4.,,RICANCT WITH SAN .JOADIRN COUNTY ORCANANCEIS. STATE LAWS. AND RULES AND
<br />liE
<br />Cr...E...i.T=M OF T1T SAS
<br />cowry. 3-031 OWNER OR Lic.assmo &owns sooldATURE CENIIRES THE POLLCIWOKI: /CERTIFY THAT RI THE PERFOPMATICE OF THE WORK FORIArbmcm
<br />MONT IS ISSUED, SHALL NOT 'EMPLOY PERsoNs sUELECT TO WORKMAXS COMPENSATION LAWS OF CAUFGRASA.- CONTRACTOR-1 IMMO ON eve-cs,a-mtcr-st.. ..----„nArsr,z If FULLS,
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<br />".I CERTIFY THATIIN THE PERFORMANCE OF THE WORK FOR WISCH THIS PEFROT IS MGM, t SIHAU. MIPLOY POISOsis iese...-oc; To WORKMAN'S C.OMPEIMATION LAWS OF
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<br />t C RSA ALL WSPOCTIONS AT CORR 440.3433.. CoMPLETE onAvymo AT LOWER AFEA mays:To.
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<br />4. LOCATION OF T.1.4Y.J.LCZ "="1"::::=L 7:1:Tre..1 CR r-ROPOSED
<br />rxrefeNce OF WA/AGE DiSPOSAL SY/OWL
<br />S. LOCATION Of WELLS WrTISH RACIUS OF ONE HUNDRED FIFTY FT.
<br />oN THE opcfPFATN, OR AO-KgRP)Pg FRK"..FS":/—TY.
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<br />014. Of CONDUCTOR cameo A-1 /
<br />IPIArlt PLAN gam.. to SAWN NAM
<br />NAMES OP STREETS OR ROADS IlEAREsT TO OR SOUNDING THE PROPERTY.
<br />OUTURE Of THE PROPERTY, MIMI COMMONS AND 1•011714 DAINIcTION
<br />DIMENEIC:"= 01210.24f.IS AND '"`CT ALL PROPOSED
<br />STRUCTURES. NCUJOING COVERED AREAS SUCH AS PATIOS, ORNEWAY5. AND 'NAAS.
<br />DEPARTMENT USE ONLY
<br />eramecOert Das I Pump iNiNscilen By
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<br />I C ACCOUNTINO ONLY: ACK
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