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i <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p S,� 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> ROM-REFUROASLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> IGmP6IF 1.TrIPRFml <br /> AF0.CATS N 1 INK BY MADE TO TNM SAN MACON COUNTY FOR A FERNI1 TO CONSTMAT ANDgn MFTAU THE MRS OESCRISM.THIS AMICATKN IO MAM IN COMRIANCE WRIT SAN <br /> IOAMN COO RY MWMINATM/ TR�tL/CHAPTER P-1/1,15.3 ANO TK STANOAR�DR/OF SAN bAaMI COUNTY MELIC HEALTH SERVICES.ENNImNMEMAL HEALTH DIVISION. <br /> IDB ADDKSe RARAI� A?V0// fY�ZQLLWN cm�c,CLiJC� PA�KELmzNAPNF �,Q <br /> wWIEp.N VF'_ l0.IL'L'lR 7'-2'i✓•WLS AaTKEe,�X GJ�6 l//�--/Y/IlY �Zeq B/AnoNEF�-5'L <br /> cOMvc,on '1' A AUOIIFY[Lf I( �2LE•Y' /lfFd NIONFyr2ASES <br /> 2.-/Yr2J� <br /> cos coxrnAc on "CARS IA. NFF <br /> TYFEOF M1i Q NEVI. c5Kr.RACEMENT wFLL ❑MoxnOM1O N4LL• ❑DTNC, <br /> ❑MSTAVATIOH ❑WELL cveTFM KF.m ❑OROs...T IFE.. ❑INMA EXTRACTION WEUF <br /> 1. ❑N.R�IMAN, N.P. CENT"MAN,OEM Fl. MAT WATER tEVEt O <br /> R ROF V <br /> ❑OVTUF BESVKE HELL ❑OEOFNYSKM WELL I ❑ bN bMNO / / <br /> o-E-I"A" old k� IASES I <br /> mI EN..O art Oil.OF WFu COxarnWTrox SPECIFICATIONS A <br /> ❑ <br /> I...I..L <br /> �❑�JJpprt RonaM A.OF weu EzeAvwnox � CA.OF caxoocron cwmm / o <br /> MFSTK VATE 'SZNAVELPACX.F TYRE OF OJOSSNOTIC' +K DIA.OF HELL CAmNO (q !A 0 <br /> ❑NSIIC pAL ''❑\\OMVEN DEPTH O F OFAVT SEAL SF£CRCATRIN A <br /> ❑SMGAT ❑OTHER aCVT 6m INSTALLEFF�.y1� OFONT SMIA NAME E <br /> ..� ❑MOMTOW aOUF SEAL ONFE ^"_ ON. CONCIO:TE FEDERK SY NLLEm❑YR IM S <br /> APHI pal ea I..CNEEMI S SOXMTO VE IRE e <br /> AA.FRO FON ,IIVCRONSNFWMO MMT1 MUD RDTART�AIR ROT. AWN1 CABLE OTHER <br /> I NEESY CE11T THAT I NAVE IPEPAAM TOEII=ATION ANO THAT TNM EARL WILL SE ROME m ACCOMYCE YSTO SMI JOAgllx COUNTY ORDINANCES.STATE TAWS.AND ANNE.ANO <br /> KOUAIpMS THE SAN MAOImI COVHTY.TOMEOWNf11 EST <br /> L ...ADEM'.SONATURE CUTOFFS THE MOVORAM:'I CEIRIA',MAT M THE KKOIMMA[OF np FORM MR W11KN <br /> IIIIR T(NYf MI..M,1OIALLNOTTM OYMFMAMWRXCT TO WORKMAN'I COMFNIFATION TAWS OF CAI RORIIA.'COMMCTCR'AIIIMNOORSUSCOMMCTXMMONATUKCERTIFIES <br /> THE ial. •I�CEIROY THAT M n1E KZINANANCE OF TOM YAIR FOR WIXCH TME FOMR IS FINFAM.I MML EM ROY KRSON I SVSIECT TO WOIIOAAN'S COMPENSATION LAWS OF <br /> [MpOKIIA.' AMICyA�N/EEMOSTCALL.W.mAENANEM POR ALL.d1111OI*NSRCTpMS AT INa wO.N}S.COMMETE R4.W1HO AT LOWER AKA}NCHAVEO, y �yT/ <br /> ENN'A LEJ. IE'L. TTX. <br /> ROT RAN OF—I.SeY.I bM. <br /> A.E.M• •OR TOADS MAKei i0 OR b11NdNA TK TOMRIY. I.LOCATION OF NOVBE SPNAOE aSPOMAL SYSTEM Ofl NIOIOSO <br /> I.11111.OF NgKRTY.ONNb aMENSON.AM)xORTN-RECTION. FAFFHNOM OF aWAOE aSPoSM SYRfMS. <br /> T.ONAFNpM oVIVNES AW IOCATON OF ALL FAISTIIO AND RaFOSEO S.LOCATION OF WELLM NTr111N MdV.OF OHIO WHITHER FAlY R. <br /> STMICTVRFS.INCLUMMe COVETEO AREAS SUCH AS PATOS.ORVEWAYS,ANO WALA.. ON THE MFI OS AOAMXO Fg1ERIY. <br /> V <br /> e <br /> WIC <br /> ©l�ON6lfQ -+ <br /> MIMEN 1 <br /> Hwy i2v <br /> SAN JOAOUIN COUNTY <br /> MFAITH SEPVICES <br /> L DaMTMENTOMENLY 1(yam, 9 <br /> R. '-O.HNN,ANNA SY E 0.1. <br /> o oN. <br /> D.N,.�pnlrw nF Dj 2""AY47 <br /> C' - :t/A g9- / S X-g-17 10gxAR'IIEE02_ 11 AfP1fW` <br /> eek <br /> ACC evxnxR Nvi MOF <br /> PE COOFI FEEINFO AMOUNT PORTIO C <XI SN TAHOVO.1 RATE I.I.IFRWC....F.O., INVOICE FV <br /> G 6 '7 <br /> Pub 4DeMh 5. ,-5'V O.I"(IM7) <br />