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APPLICATION FOR WELLIPUMP PERMIT <br /> ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA,.0002 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete M TI(pti-fol <br /> AMWATWM IN INIIE NY MACE TO THE MAN JOAOL"COUNTY FOR A PERMIT TO CONSTRUCT ANDROR NNFTALL TIIE WORK DESCRIBED.TIM APMtCAIION IS MAOE IN CO"MfANCF WR If EAN <br /> JOAOION COUNTY VfVELOPMFM Trmt.C11APPTER 9.1 1 15..3 AND To If NTANITARDM OF MAN MAOUM COUNTY PURIIC IIFALTII METNICEm.ENV!"...NIAt WALTII..N, <br /> "S ADORTSWOR ATTIW <br /> , I W T �QI F� J4i,kl CITY_ IQ;pov, PAnCEI WMAPN, <br /> OtNKn'S wAMe_-N ?s Iff�9G'� O+l A110RES9 21.5 W. A4%u'A SA-Atf. &6o, RIGHT, <br /> CON.RACTOR SlW ,. ICt�Wpt�� l'.O�d OV-LaiJ'o.1 ADDRESS Iy.0 (T.*A(tSA� Qf, ue,51 <br /> //0]]floQQ1 naNEFZ�9S <br /> MVM COMRVICTOR F�t t� ENJ\+Qhrnt».�I AlTdrteS 3v5.SuQ,ri Is I-(a Lt� ,bUO3 U�S nD,NE,Z04�•-'��� <br /> TYPE OF WKVPV P; C1 NEW WELL ❑REMCEMENT W'Ett ❑MOFIROMNO WEtt, OTIR/l <br /> Ci MMTALLATM]N ❑Wnt.SYMTEM RFPASI ❑C"O"CONNTCT REPAIR ❑VAPOR EATRACTON WELL, J <br /> ❑NRr❑T1w.W N.P. OEM$#n/EAP a" FT. 11RIFT WATER tEVEt p <br /> RYPE OF"Mr) <br /> ❑ol/T.OF.MtRVlce WWftt ❑OtonFYm k wttl, tropts—SIONO Z- 30' • <br /> Q OEST/MCTOIA <br /> IN IEJIOEO USW TYPW OF WELL CONSTAM110H SPECIFICATIONS A <br /> El'+ STRIAL ❑0"N mOTTOM DIA.OF WFtt fXCAVATON ZT tXA.OF CONOUCTORCA9.M Ulla• p <br /> 13 OMESICAYWVAlf ❑RMvnrACXPK" TYPE OF CASNNIIITItIFF' A MA.OF WFLt CASINO <br /> Q TVM WAR/FAc1PAL A❑.,.O'-wH nuns#of DROUT SEAL 30,1 � , O4CTTcAT1oN /A�/�I.4 , <br /> N0 Wmn All IAO HE OTHER OROW SEAL maeTAttEO BY RRNE� A OROIFT I1MND NAME aEyr 10...k''S w RRyy E <br /> IdT MOMTOIMM 2^ nn-- 11 GROUT SEAL FVW*O:❑Yr 17 F1. CONCICTe PEDESTAt.SYORWLLERRE V- t7TN S <br /> AP.RGW,OFFTH � '1"L C.Y tOC*MO CNESTEn 111O2/01TOW Pwq (t S <br /> PROPOSED CONSTRIICMXSMttINO METHOD: MUD ROTAnY ADI ROTARY AUGER CABLE OT/KR Lfa 1TEL�-�� <br /> I ITE^F.SY CEIIToN THAT I HAVE PREPARED TNM APPUJCATPON AND THAT TIIE WORK WN.L RF DOW IN ACCORDANCE WITH SAN JOAOUN COUNTY CROMANCES.STATE LAWS,AND RIRES MSO <br /> TNOVUTONS OF TIIE SAN JOAOUN COUNTY.HOME OWNER OR LICENSED AGENTS MHATVRE CERTIFIES THE FOLLOVRND!'1 CCWTIFY THAT of TM PfAFOMIANCE OF TIIE WOTK F01t WRRCII <br /> TIN*P[T1MiT M MOVED,1 SHALL NOT EMROY PERSONS IOU"CT TO WORKMAN'S COMPWOSANON LAWS OF CAUWOIMJIA.-CONTMCTOWS IWW 40 OR MCOMRACTM SOMATUAF CERTRRS <br /> TIIE FOtLOWWPNO: 'I CERTIFY THAT M TIIE MATORMANCE Of TIRE WOM FON WHICH TINS PERMIT M 1MSUED.1 SNALL EMROV PEn*ONS SUIIJECT TO WOORMAN'S COMn.ATON LAWS OF <br /> CALIFORNIA.'TTM A►RJCAURT MUST CALL 24 HOURS IN ADVANCI FOR ALL REMMWD019POCTONe AT t2ME 409442E•COMIMCORAWmb AT LOW[R AREA TTOVIOEO. <br /> - <br /> TOO. I.A..�t.c.,k F rl aM.c�<,�� DN. �Ol Z3�.y 7 <br /> ROT TUN D..W a SMrN M.I. AS Slhv"'1^ <br /> 1. HAWN Of*TREFTS OR ROADS WARIEST TO OR ROUNDING OUDING TNN PnDPERTY. 4.tOCATOSE SE <br /> N Of HOU" COMEOSAL SYMFM On PROPOSED <br /> 2.RIM NIC OF TIE TTORAT'.OIVNO DNAENSONS AND NORTH ONIECTON. EAPANN"OF SEWAGE DISPOM SYSTELLS. <br /> 2. DIMENOR"O OUTt1/NS AND tOCATON OF Att IJUeTWO AND M%"OSeD S.LOCATOR OF WELLS WITHIN MONS OF ONE IRRNNEO fsr,Y R. <br /> STRUCTURES,INCLVOtNO COVERED AREAS SUCH AM PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJONNRNO PMP'EM. <br /> L <br /> C - w <br /> F/ xY a V) <br /> d i Z <br /> g <br /> oo, f g$ <br /> 00 a1 <br /> y ,•� '� X31 <br /> .ATn11q � � r <br /> DD TI.ATOIT N A <br /> EE f' 3nN3AV 15(IOOl <br /> OE►MTIMFIfT me ONIY <br /> O«. <br /> of D.» FI..v Lr...*.n N OM. <br /> un /f-AAD <br /> ACCOUNTING ONtY: AO, FAC, <br /> PC COO" FEEIMO AMOUNT SUAITCO CNECIKOMASH RECBVED MY OATC PMMTNSUMCE PEOUCS T If11IASD1 OFVOPCE <br /> 122 11 �• D ILiI <br /> Pub.Health Serv.-EIMTo.173(V97) <br />