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APPLICATION FOR WELLlPUMP FERMI- <br /> SA DAOUIN COUNTY PUBLIC HEALTH SP_'CES <br /> v ENVIRONMENTAL HEALTH DIVISIOk d <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)46&3420 <br /> RDR•REFURDA}ILE PERMIT EXPIRES 1 YEAR FRDRE DATE ISSUED <br /> {Cewglele In TI+RestPl <br /> AIT111:AMN IN IIFFE RY MADE TO FNE BAJI JOAOUW COUNTY FOR A PCFNNT TO CONNIMM-T ANOAR NIIAM 7NE WORK UERCIINEO.TINE APTtlCAION M MACE M COMN'LtANCE Valli SAN <br /> JOAQUIN COUMTY OEVELOPMEM INIE,CNAOtER 9-1116.3 AND TIIE NTAMAMO OF RJIN JOAOUN COUNTY PUKIC IIEALt11 SEINICFI,EMVIONMEMAL HEALTH DM01OM. <br /> JOS AODFAI R AAFNr_Tl�L� --9_ .s. A�/�PO If T WA/0,ycnY--4ry�CJ Tz6j-`-i ei'1 ►AncTt�/R�ErFFnN T <br /> ON'FRRY NAME v •t� •{nLJ AY }� y�'I C�GI/l -A1Nif1�eT !/�\�S[�7 .p�. !+/ff�` J���A7 nIVN�17 /1. <br /> CONTRACTOR �JdI+111G/A�Y LR.ICIJ•/VAOEIRfp_&0_ 2,t 334L 110 "N' OO 111011E%�J4V <br /> "eON7RFCTOrt }'-1 ADOW011 UC► "SOME 0 <br /> Tyr[OT WELLIPITM►: ❑NEW WELL ❑REPLACEMENT WELL ❑Ma1RrGRINawnt f ❑OTHER <br /> E3 nINTALLRTION ❑WRI,F"TEM REPAIR ❑CPOSe<ONNICT REPAVE ❑VAPOR[xIWTOH VYETL r J <br /> ❑u-❑r-.6 H.P. CKPI"rRRMF S[T_FT. TINNY WATER L[V[L O <br /> O YPE OF PUMPI <br /> ��S(( ❑OUT-oF-eTRaCE w tL ❑OEOMIVMAI WILL• ❑ MR T1017N0 S <br /> iNI ENDED UsF IT7E OF WELL CON[TRUCUON eF[CIFICA1lDR& A <br /> ❑NOMI/TRIAL ❑OIEN NOTTOM DIA.OF WELL E%CAVAI" OIA,OF CONDUCTOR CASNIO D <br /> ©OOM[RTICAMSVATE ❑GRAVEL FACxMMIE TYPE OF CANfNQA1TT[t1PVC //C_ 01A.OF%Vnt CANINO Z+ <br /> {J O <br /> a PlMlCAIINNCIPAt ❑ORMN tMPT11OFOROUTWAI�, �. YO INECRICATION n <br /> ❑NWNATanrAO ❑OtNFn GROUT STAt TNFIAtt[V BY ORDUT BRAND NAME E <br /> ❑MCWTONMO GROUT TFALPU0tt1l,❑Y- ❑N. CONCWEPEOESTALFVDFIALLR❑Y- ❑IIr s <br /> APPROX.Derr" toanNG CWNTTA soxerrow PIPE d <br /> FROPOFFO CONSTRUCTanrWTLLTMG MRNOO[MIA)ROTARY ANI IOTARY AUGER CAER.E OT7IFIL <br /> 1 IIE^TnY alai"TIIAT I NAVE PREPARED IF"S ATL'UCATON AND t11At 111E WORK VALL N DONE 1N ACCOIOANCT VNTII FAN JOAO"COUNTY Onr)MANCEt."Alt IAWt.AND RRES AMO <br /> RELILRATIONS OF THE SAN JOADLIIN COVNPY,HOME OVMM OR LICFTItlD AOTNT'F eONAtURE C11"K11I THE FOLLGVRRG:'1 CETMRY THAT N THE FTWOO MANCE GF THE WORK FGRVNFCN <br /> TIN"/MART III IO"UED.I"IIAI.t NOT IMMOY PFII"DNR SUBJECT TO WC"llMAn'1 COMPINIAFaM LAWN OF CALIFORNIA.'CDHtIlACT01T/111S11O OR MIB{CIIIIVICINIJ SONA11111E C[NTRT[■ <br /> TIIF FGLLOWtNOI 'I CEMRY THAT N T111 PERFORMANCE OF TITS WOFR rnR VARCM Tfirg PF E1TR IF 1961".1•HALL FMPLDY PERSONS SUBJECT TO WORO"AWO COMPFIMATION U1VFf OF <br /> CAUIOM"A A�T CALL L NOT1111 N AOYAMC R ALL RFOU111Eo NSPECTIONO AT 1!111 4"_1",COMF101 DMLV"/IG AT LOWER AREA PROVIDED, <br /> W.-W x TI"r ff?1n�eAd GAS.___.JE1Id Alf 41,rof D.1. 1/ Q 171. <br /> PLOT PIAN 0-n Br-IN Mw •N <br /> 1, NAMFN OT RFnFFFI OR ROADS 14AMPT TO On ROEAROM 7111 NIOTERIM <br /> CM 4.tOCATNW OF IMV"[WWAOF OIRPOM IEH M1TOFOFED <br /> },OVILNrF OF TIE[TTgFlRTY,MVMro ODKNlION9 ANO NOMH 01KCT1oM. ExPANN ON of SEWAGE dqV SAL WeIEMe. <br /> 3. CIMF11"ONEo oVILRIFS AHo LOCATION'"ALL <br /> ALL Ex19FMO AND <br /> PROPOSED R LOCATOR OF WELLS WDWN0 RADIUS nT ONE NUMOn rMTV M. <br /> "TFWCTVREF.PiCtDOOM COVHEO AREAS IUCH AN PATIOS.DAVEWAYI,ANO WAUL9. ON TIIE PROPERTY OR AOJOPMM P/1aPERTY. <br /> .............. .................._......... <br /> .-:.......-.-. <br /> DRMtMIRR U1111 ONLYff <br /> M�11rwV...Aw F 9:W 1- hr <br /> Mw"YrF 0-SF O"" P.FM Y­don SF Urlr <br /> n,»F..."1... Rr ON.C­ <br /> LI <br /> ACCeUNTNG ONLY: AICR FAC, <br /> !F CODES FEC'IMO AMOUNT MONIIED CltLC"MAIN RFCOVEO SY DATE P1F1MlTrI1FffVMf REQUEST NUMBER INVOKE <br /> Pub.Heath Serv.,EWro.173(1187) <br />