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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICESENVIRONMENTAL <br /> TH DIVISON <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 WELL / P U <br /> (209)468-3420 <br /> kOk•31 U1f0ABLE PERMIT EXPIRES I YEAR f11OM DATE ISSUED <br /> APPLICATION la FERE My MADE TO THE BAN JOAOUIN COUNTY ICISTpISTS 4alk <br /> Ttofs) <br /> iOq A PEiWBt To CONSTRUCT ANLOroR INSTALL THE WORT(OESCRILHED,THIS APPLICATION IN MAGE N COMRA.N <br /> ICE WITH <br /> JOAMIN C.Ot1NTYOFVELOPI.IEHT TILE.CHAPTER 9.1115,3 AND HE BTANDAPDG O AMN COUNTY PUBLIC 11 TH&ERWCE ENVIRONMENTAL <br /> S. HEALTH OMBION. <br /> JOB AODMBS/o0.A�PN]i CITY d G�.�-�� P R BRFIApNI <br /> OVVWA'e NAME�I ✓K L (j� Yyln-moi _ / D — <br /> � ADORES& <br /> CONTRACTOR ADORE // 11Cl �P'.DHE jZ:E <br /> al/B COMRACTO <br /> AODRESe LUGS HONE v <br /> TYPE OF VMLJPUMSP: ❑IIEW WELL ❑REPLACEMENT W[lt ❑❑MOFITOPMO WELL F ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAM C}CROSO-CONNEECTTjM�►AIR ❑VAPOR EXTMCTNiN WELL/ •) <br /> IT YFE pvMly ❑Rep.lr H.P. DEPTH PUMP SET.7f RFT. FIRSTWATUMLEVF-L/rIr- O <br /> Ll OUTOF-BER VICE REL[ ❑OEORRYWAA.WELL F ❑ WIL NORM a <br /> ❑OESTRIICTION: <br /> INTENDED USE jT►E O CONSTRUCTION 1PIMIFICATIONt A <br /> 11 INDUSTRIAL ❑OPENBOTTOM DIA.OF WELL EXCAVATION CIA.OF CONDUCTOR CASINO G <br /> ADOIAESTICXWVATE ❑GRAVEL PACKtVZF TYRE OF CABINOMTEEL/P C CIA.OF WFLL CANING D <br /> ❑PUNUC/MUMCIP/LL ❑DRIVEN DEPTH OF OROLTT BEAL 11KCFICATION A <br /> IEE&OATIOWAO ❑OTHER GROUT SEK INSTALLED&V (gpUT BRAND NAME E <br /> ❑MDFILTORINO R�r GROUT BEAL PUMI'FD:❑Y.. ON. CONCRETE PMEBTK BY DRILLER❑Yr ON. <br /> TS <br /> APDX.OTTN LOCRINO C1EaTFR SOX/aTOVE PIPE S <br /> PROPOSEb CONSTRMTION/DIBLLRNO METHIOb;MUD ROTAVY ANI ROTARY AVOE/I _CABLE OTHER <br /> I HE9EBY CERTIFY THAT 1 NAVE PREPARED THIN APPLICATION ANO THAT TIM WOFK WILL SE DONE N ACCORDANCE WIRY•RAN JOAOMN COUNTY ORDINANCES,RATE LAWS.AHO RULE AND <br /> REOUTATONS OF THE SAN JOAOUIN COIlN7Y,HOME OVVHEP OR:ICENSED AGENT'S BIONATURE CERTFIES THE FOLLOWING:'I CERTIFY THAT N THE PE7FOR MANCE OF THE VIMK MRVNIKH <br /> I'leTHSPERMIT Ip ISSUED,19R4ALL NOT EMPLOY PF"M p JECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.'COMPACTORS HSRINO OR SUB-CONRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT N TH RM F OF THE WORM FCR WHICH THIS PFJOMR IS ISSUED,1 eHA'.L EMROY pfpwm BUSAV TO WOM MAWS COM ATION LAWS OF <br /> CALFORWI A CAM MUST lA0 IN OF FD.I ALL RENJURFb IRNRCTTONI AT 12851 A&1 JM22.COMPLETE bP1J1W11N0 AT LOWER AMA <br /> PFgV1DEp <br /> sl&•,,A X <br /> PLOT PUN VD Ie S..NH 1..1. 'te_ <br /> C NAMES OF STREETS OR ROADS IEAMST TO OR BOUNCING THE PFWVtTy, A-LOCATION OF HOUSE SEWAGE OIWOBK SYSTEM Op FROM BED <br /> 2. OUTLINE OF THE PROPERTy,OfVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF KWAM DIWOSK SYSTEMS- <br /> ].IIIAFNSIONEO OUTLINES AND LOCATION OF ALL EXISTING AND PSDPOSEO 1.LOCATION OF WILLS WTTI N MDIUB OF ONE IMNDRED iFTy FT. <br /> STRUCTUMS,INCLLIDND COVETED AREAS MUCH AS PATIOS,DwVEWAYE,AND V!ALXe, ON THE PROPERTY OR ADJOgANO PROR4RTtt, <br /> i I <br /> t r <br /> I <br /> J <br /> ..... ac,I �d <br /> N <br /> : A <br /> c L �':Y <br /> :.. : Z'L ry e <br /> Y• VIT��I I � , <br /> f. <br /> NAV .... ,. . . .. <br /> SAI.t'M'/"P�ZN=`�.AIJ�Nt9tt7N.; ., - ... - • <br /> ......Y A.w ...............3 , <br /> ............. . p 370. <br /> (f +��� OSPMiM9NT <br /> US$ONLY <br /> n(rptb.lkn Av..Ft,d SY ^ .f� C 1 1•A���••�LC/ •---• o,h -3 ' _ 1�'� <br /> ar.w IrNpw.A.n BT o.0 PumP Inro<Ii.n BY__L JN--•i'1' (>•j•,.} �, o.NS uz <br /> On.IrN,tl,n In.P.01Nn BY_ D.tt <br /> CommdNr <br /> ACCOUNTINGONLY: AHM FACT <br /> . 71 <br /> PE COM FEE INFO AMOUNT REAETTED CHEc ASH RECOVED NY DATE PERMGTtamm I/VCICd <br /> =tom 05 1 4'SZ7- 19se6's i <br /> —71 <br /> Pub.Hearth So"-Envira.173(1197) <br /> l i <br />