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APPLICATION FOR WELLIPUMP PERMIT <br /> AN JOAOUIN COUNTY PUBLIC HEALTH SERVIC' <br /> Nom/ ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> 110U•RE►UMDAUE PERMIT EXPIRES 1 YEAR rNDM DATE ISSUED <br /> ICOmpIN/In Trlpllenl/1 <br /> AMOCATION Is IIErIE NY MADE TO TIIE SAN JOADVIN COUNTY rOR A PTIOJIT TO CONSTIRICT ANDIOR INSTALL 714E WOW DEACRIREG.TIE@ APPLICAt10A1IS MATTE N COMPLIANCE WH71 SAN <br /> JOADUN COUNTY DEVELfOM"W TITLE,CHAPTER 8.1 116.3 AND TILE STANDAnns OP SAN JOAOLRN COUNTY PLIRLIC IIEAUl11 f[MMES,ENVNIONM1W1AL HEALTH Omm it. <br /> .Las ADb"tvvmn AEN1+ l)G CRY 1 L&�TU_j PARCEL mZE1NY11 <br /> OK71EI1's NAME ( I �7"on! AOoWBB jtP Oy�/R-TL-anno l-o ev-b. MIONE E a a'1 4 G G Yj s9 p <br /> CONMACIDq I_� V l�T 2L!-'f 1:n]r� ADUPEBB 4 5>;1 'AV�CO FJ LJ�Lie/ ?��2_-FIIOL.IE 1 1 O 37.7-q�oCl <br /> SVS CONTRACTOR.S 1 •i- M Ex 1'L_D R"rl Q N AOIXIESS ^ � cQ C 4 T f �/ 4L <br /> c n 11- <br /> TYPE OF WE M. ©NEW WELL ❑11FPLACEMFNT WELL ❑MoNH ONNO WELL/ ❑OTHER <br /> 1❑y INWALLLATION ©WELL SYSTEM REPAIR ❑C"085-CONNECT REPAIR ❑VAPO I ExtRACTION WFtL• J <br /> LJ N..,❑p—.a H.R. DFPTII PUMP SET"'..Fir. VEL. FIRST WATER LEO <br /> HYPE OT MMPI t3 <br /> 1' 11OUT-OP-SERVICE WELL ❑GEOh1YSICAL WEt1 I ❑ son.RommO a <br /> NTENOED V/E T R E CONSTRVC11O W—ECtFICAI DONS A <br /> 11*1111IMMAI ❑OPEN BOTTOM dA.OF WELL EXCAVATION OTA.OF CONOMTO"CAROM O <br /> 0y nOMF.SM07'SVATF ❑OMVEL PACKMIr TYPF OF CARNOt6TEEUPVC TNA.OF WELL CABNO p <br /> 1.1 NRLICRMlNIMAL ❑MY" DEPTH OF OROUT SEAL 6111011CAT1ON R <br /> ❑I1"OA111ON/AO ❑OTHER OnGLIT{FAL 10"ALM BY anout BRAND NAME E <br /> ❑morimomNII nnTIVT SFALE'UMMO:❑Y.. (ITlw CONCILEtE PEhtnI AL BY INTRI PIF.©Yr ❑Ile a <br /> APHIDS.TIM" LocKINO CIIE611n sOXretovE rim <br /> a <br /> PROPOSED CONStRUOTIORMBILUNa MF7ROD:MUG ROTAFTY Ain FOTAITY AUOFr CABLE OTHER <br /> 11 It'IftY CFRIVY TOIAt I ItAVE HUPAMF)111111 APPLICATION AND tIIAT TIRE WOOK WILL BE GONE iN AC.COMANCF WITH SAN JnA"COUMY OHNNANCEs,STATE LAWN.A"n mS.Fs AN; <br /> IIFOLIlAt1ONe OF TIIE SAN JOAOURI COVNTV.NOME OWNER On LICENSED AOFNT's AIONATUrN CFntwrEs TILE FOttawria:I CEM Iry Iltht WTI"FIFFFOIIMANCE OF TILE WOrK ton WIKCII <br /> TIHR PLTOAIT IR MSUT0,F mRAI.L NOT EMPLOY PENTIONB SUBJECT TO WONKMAN'S COMMMORTION LAWS W CAtlFOTtlaA.•CONTRACTOR'■IDIRq On TNs COMMCTOM mOHAtUNE CETNRs <br /> TIN FOLtOWINO: 'I CERTIFY THAT IN 110.PEttr0TWAA"CF OF 711E WOM POR WIIICtI line FlnMH IS ISSUED,t SNALL EMPLOY MOO"$0U L/ECT TO WORIWAWO COMPnI/ATION LAWS OF <br /> CALIFOIWIA.' TNT AP CANT'km LL 24" UN ADVANCE FOR ALL REOVNIFD N/EECHONi AT I"01 46Sa4ts.COMPLETE GNAWING A7 LOWER AREA POOVIbEb. [/(� <br /> elr—t x r C�1 ......._._ Tm.�e,St,e.Y' <br /> PLO IM7 HAN "N`d-I <br /> I.NAMPR Or RTFUEFO On MADI NEAREST TO OR ROUNfAm 711E r7WFERtY. 4. LOCATION OF IIOUBE BTWAOE DISLOIAL SYRTFM On roorosfG <br /> 2.D1HI.RIF OF TIM ro(ITTRTY,OMNO VIWNOIQ148 AND NO ITII Ulrltct ION. MAN11ON Of SEWAGE DISPORAt SYsTEMs, <br /> /.1110AFRO WIFO OUTLOITB AND LOCATION OT All MRT1NG AND rT1OPOAFO S.LOCATION Or writs WUIIN MTNUs DP DNF INNDIOD tUTY 9-T, <br /> Sf HUCTUMS,NCLUDINO COVERED AREAS SVCII AS PAI LOB,DRIVEWAYS,AND WALxs. ON TIIE P11014RTY On ADJOINING roorSRTY. <br /> bEPMTMRTT USE ONLY <br /> W M L..pl.;llln sl O.I. Wn'P LMR.Eelnn SF D.I. <br /> 5 e,kcj 10 <br /> ACCOMTINO aNLYI ARD/ FAC/ <br /> PE CODES FEE INtO AMOUNT REMITTED CIIE"OfCAM RECOVEG NY OAtf PETMI7TSEJIVICE RLOUEST Nlxatlll TffinelE <br /> 2 ID.3 i01 LA 097 <br /> Pub.Hearth Gerv..Envlro,173(1107 <br />