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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)468-3420 <br /> UON•REFUNOAILE PEAM11 EXPIFES I YEAR FROM NAT I MUM <br /> APTLICA7roN Is NFRE sY MADE TO t"E SAI/JOAM N COUNTY FON A PtMff TO CON/TIaICT ANVMRR INVTALL THE LVORL UE[CM@Eb.TIRs AMXICA,MM H UAM IN COUKtANCE WfTI1 SAN <br /> JOAQUIN COUNTY--LC MENT TFTLE.CNAPTFR B•1 1 16,2 AND THE STANDARDS OF SAN JOAOURI COUNTY FUsM 111ALT11 sEamo FNVTAONMtNTAL IEALTH DRRSK*L <br /> I <br /> JOB/1DORESSAORAPNf 1YPY�� -4 _CRY_�scfld <br /> PAJICEL eIANIF_I(�AJC <br /> ON?RIYS NAME /� <br /> ADDRESS 7 d .+• ` PIRIN(/ ykC-J � <br /> COMMACTOn <br /> AoplEn ) ucr-1z�3 <br /> '•elw caIlRAeion PHONE r <br /> tpimPl�'� l <br /> N! <br /> Ftn.Qmmm 13#Aw WELL ❑/El1ACE[E[NT WILL ❑YOES mom N4LL f ❑OTHER <br /> 11 0 wsTALIATbN Q WELL WMEM 11EPAIR ❑cROswcomacT REPAIR ❑VAPOR E7[TIIACTION WELL <br /> i ❑N+,+❑ppb H.P. 0 <br /> E RYfE OF fVLIPI OEPTII lINA►S!T iT• FIRST WATER LEVEL O <br />!!! ❑MIT-OMERMC WELL ❑oE"wvcAL WELL 1 H soR 1pT/Na RFV <br /> ©DFSTIM rsout l..y I.�. .1 �lri.*.�, I ^7 <br /> • <br /> ❑slDllslfSAL so Ma Int or Z!lm <br /> ❑OPENSOTTOy Otk OF Vvm A FIICAVAT1oN A <br /> 13DoUESTICR'RIVATE ElONAVEL FACRAgE OIA,OT CONpCAMINO SOO�`� <br /> TYFF Of CASSgISTEELRVIC A Dill OF WELL CASINO O <br /> El MOLICAM AL ❑DAMN ERD <br /> DH OF OIIDIR SEAL //YJ �f.1f _ t1•ECE1CATgN <br /> ❑IANOATOWAo ❑OTH[II GROUT/EAL 0WAlLEDSY S <br />' ❑11015►OlENO ORDVf SIIANO NAMf_ ! <br /> ll OROLIT SEAL PUMM R I]Y- ❑m.v <br /> APFRO 1 A ❑W S <br /> 1 L l►TH (1 rf�' }.J' CONCRETE P[OESTAL sY WELLUL•QYr <br /> LOC7[sO CH!n[R sOlUnovF rIPE s <br /> I PlblosED CO NSTVUCTIONl0111LLDM MSTIOD;MVV MOTARV AIR ROTARY AVOEnCASTE OTHER _ <br /> 1 NT'E1Y CERTEY TIMI I IIAVE PREPARED TIs1 AWr1CATON ANO THAT 711E WON[WILL SE DOME M A.CCOMANCE WRIT SAN JOAOUW C011HTY OPOIHAJN:[1,STAT!UWt,A1ID FEAES ANO <br /> TF"PE WTI Is THE SAN JOAOUH COMITY.NOME OWNER OR LICENND AOENF7 SRINATUAt CE11Ts'RS TTI[roLLOVMM:'I CEIRIFV THAT RI THE PE1f'OMAANCE OP tllf YAOIK IM WHKN <br /> THE RISAlT Is HgRO,1 p1A11 MOT El1ROY PERSONS SNSJECTTO WOAKMAN•S COMMMAIION(AWS OPG OWNIA'CONTRACTOR'/HnEND OR W6COMFMCT00 IIONATIMIE CERTIHEs <br /> 711E PDLL01NDO1 •1 C[RTtry THAT Nf 711E rtRPONAAMCE OP THE WOIR PDR WHICH 71Ss <br /> WTI b Heim EMPLOY PERM"sUaFECT TO WORWAWO COMPDIIATION LAM OF <br /> CJWFOM1IA,' TIR A"MANT MWT CALL 24"0"w ADVANCE FOR ALL REONII4 IMMMNs AT I •SIH.COAOr[TF DIMwDIa AT LOWER MEA PT!OVIO[O. <br /> f wrr a <br /> •N <br /> 1.MAAIE/OF SRES <br /> TIEETS OR ROADS NEAT 7O OR NOUN OPLOT MAN 401—N"W.l S.W. <br /> INa THE FMPERYY. <br /> 7.OUTUNE of TIR rRortn",ONMO DtMTNSONS MID WORTH DOI[c71aH, S•LOCATION Or"DUNE IMAGE pePO/K SYSTEM OR PIDfpiFD <br /> 7.DII4Et11011E0 OtlTUNFl AND LOCATION Of ALL EXMM AND PROPONEO U[FANwRl OP SEWAGE OI1rOSAL/Y571MS. <br /> STUB"Mk r CWDIIO COVERED AfEAC SUCH AS FATOC DHVEWAVV.AND WAL[s. S•LOCATION OF WTUS WITNl RAORIs OF ONE HUNOMD sY7Y ri. <br /> ON THE rROP[ TY OR ADJOIHIM PROMrtTY, <br /> ...:...... . <br /> A <br /> • :: '�' sem_ J.. <br /> J. <br /> r .... <br /> r <br /> 1 <br /> . <br /> y <br /> I '1 <br /> Ad Or '��. ! �^!�' DVARTTADrr us[aRtY fes] ...+. <br /> A1P/..II.R wHn 4 o'�^L.I 1 1` I 5 <br /> OpwA L' O. By <br /> o.I. <br /> C-. <br /> ACCabRHNa ONLY; Alp/ FACS <br /> re cools FLi llfTO AMOUNT RvAEt[v CH[CErRAIH RECEM 1E DATE <br /> rpowl'AlurACE RIavuT IRMIM mvml <br /> Sec II c <br />