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APPLICATION FOR WELL/PUMP PERMIT /) <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NOWAVUN0A0LE FERMI EIIFIREI I TEAR FROM DATE 133110 <br /> IC.IRLtMN U TTyb.tll <br /> APPLICATION M HOE N NAGE TO THE SAN JOAOUN COUNTY FOR A PERMIT TO CONSTRICT ANVAOR INSTALL THE VVGRI DESCRIBED.TIM APPLICATION a FRAM IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEMMWENT TITLE_CCHMREII$-1115.3 AND <br /> THE STANDARDS Of BAN JOAOIIIN CO_UUNNTYY MXILIC HEALTH SERVICES.tNVIft7N WffAL HEALTH DIVISION. <br /> JOB AOGIIE.MO11 APNf_ - - ��Y./ ( (jndI E lY 1 CRY PAICfX 7REMP'MF <br /> OVVNFA'.NMRSV'_ ADORES. PHONE f pR� <br /> CONI R1ETOR fir{� � ADOaEu b�-�E/(o n R L ucl ,p'��rF1oNE R�iY�a18"L`�E <br /> .IR.IGNTRAtroN ADMM tJCf fNONE f <br /> TYPE OP weu/nllil: ❑NEW VINO+. ❑NERAeuaw wELL ❑MotwrolwIO WELL f ❑OTHER <br /> ` ❑NSTAIUTIM1 []WELL SYSTEM REPAIR ❑CRON/cONNECT REPAIR ❑VAPOR EXTRACTION WELL• 1 <br /> ❑NIP❑Rq.Ir HJ.3 OEFFHLORP SERAL.LFT./12Aj0g- FIRST WATER LEVEL- O <br /> RIPE R71JF1 <br /> ❑olT-0pLeew CE wELt ❑GEOPHYSICAL WELL/ ❑ .GN.scro O S <br /> � ❑DE.fRIX:,10N:��li�.�1L4��.C�Lr� .L.f-� -- <br /> Elm <br /> OPTHIN 8PIMMAT00041 A <br /> DU <br /> ❑SnEAL ❑OPo!SOTTOM A.OF VVILL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑DOWIFFICRIRVATE ❑GRAVEL PACRMM_ TYPE OF CASNOISTEEUPVC DHA.OF WELL CAlINO O <br /> ❑KRILICNIUNICIPK ❑OMEN Ol"H OF ORRWT SEAL SPECIFICATION A <br /> ❑SMBAIRWAO ❑OTHER ommr am PwALJFD SV WRIT GRAND AAAIE F <br /> ❑MDHIT=" lawlm. Grow.RAL PVLNID:(3y. 0m. CONCI4TE PEOEwr^L SY DIRLHp❑Yr ❑HH a <br /> WLIOX OVEN LOCKING CHESTER BOXISTOVE FIVE a <br /> PIIOPOam commmviouAfAm NETN00:wm ROTARY___AIR ROTARY AUGER CAME OTHEIL <br /> I IRlfY CERTIFY THAT 1 HAVE FREFAREO THIS APPLICATION AND THAT THE WORK VVRL Q DONE N ACCOHOAN-E WTH SAN JOAo11R1 COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> F40ULATKWV OF THE MN JOAOLIN COUNTY.NOIR OWNER OR L1tENSR,AGENT'S KONATURE CERTIFIES THE POLLOWRR:1 CERTIFY THAT N THE FENOIMANCE OF THE WORK FOR VMIICN <br /> THIS PEFWIF A tSNEO.I SNAIL NOT EMFLOY PERSONS 9tXL*CT 10 WORYOAAf S COMPSNSATON LAW.OF CNIFOR NIA.'CONTRACTOR.HIRING Ge W§4'QF TRACT.10 g1ATUM CERTIFIES <br /> THE PORLOW"! It CEIR OAT N TEE 1'EHIFO/RIANCF or THE WORK PDX VVFHCN TRIS IS ISMETJ,1 OWL EMPLOY MOONS KMACT TO 1FORRSIAN'S COMPENSATION LAWS Of <br /> CALIFORNIA.- THIS T CALL N 110 ALL IR'III11M TIO"AT Or IMJdIA.COE M"t ONA"Al AT LOWER AMA PROVIDED. <br /> SIPId X Ti", 9�'3 �/ <br /> PLOT RAN R)--1.MSM SIM <br /> I.NAMES NN/THEFTS ORI ROAD.NEAREST TO OR BOLNDI G THE PROPERTY. t.LOCATION OF HOUSE SEWAGE DOPOSAL SYSTEM OR FROMOD <br /> E.OUTLINE OF THERIPL <br /> !/TY.GIVI G DAMINRIOHy AND NORTH ORECTION. EWANSOIR OF WWAOE DERfl O/ SYSTEMS. <br /> ..OEAEN.RPEO NF. <br /> OVTLS AND LOCATION OF ALL EXISTING AND PROPOSED I.LOCATION OF WELL@ WITHIN RANIII OF ONE HNRa"D FIFTY FT. <br /> STRUCTURES,SICLIIDING COMM AREAS SADA AS PATIOS,ERNEWAYS.AHO WALKS. ON THE FROFERTY IM ADJOI IOD FROPERRY. <br /> SSSS:.. <br /> J <br /> . FLW4AO <br /> mit � • <br /> ✓k <br /> .v • <br /> ENT�.� AUQ s,.9l . <br /> ��'4P I��.hUU11J U�UN I Y <br /> _ • pUBtIE HEALTH SERVICES <br /> SSSS. T VLS <br /> CIJVIRCYNMENTALREAL H.D{ POI'S <br /> vermliewIME ONIY f Z <br /> Af1PM.IMA A...FR.d M_ O.N. v/V�- A- <br /> 0-4 1 PWI.w ST— 0.10 P\ bI.—S—M <br /> W&A.<oil eGD ? <br /> ACC0IRJTNO WILT ADf FACE <br /> R 2001. ►Q NIFO AA.pLNiTTW C :CAIN 11lQRVEO■Y DATE PRIAITARINCE 11E01EJT MIMSR INVOICE <br /> o <br /> Q n H, n — - — A-a <br />