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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ; <br /> a{ tlI-:jpj ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 385, 445 N.SAN JOAQUIN ST„ STOCKTON, CA 96201.388 I <br /> j,�L l•' ll�, (2091468.3420 <br /> K MOM RfiUI10A9 -R-M-J MIRES I YEAR fRUME_OATE ISSUfa I <br /> ION <br /> Ig <br /> ploro <br /> JOA4IC COL N yJ" IL'70 THC 6AN COUNTY 1UR A".MIT TO 1:IUh5;hIC114 i) �TAli +t,lWo, IHIi:AfTlICAIIUN 10 MA()(!N GgM/k-IANC[LYfIH 6Ary <br /> �AGIRfI COUNryIENT TITLE.CHAPTER B-1l15.3 AND THI 6TANOmtpS OF FAH JOAOIUN CPW"y PUMIC fIFAI IH 61nVICE9,fNViRO!1MfNTAa.Ir[ALTle I71vISgN. <br /> JOeA VURESS/0Rk/[.l-__ ;, I M�.—•/ ;'! i <br /> OWNER'6 KAM[ 5I - !/' 1"!f: /.l I CITY---`=-G[._i-'-• pA11CfL ellEIAFHIf "f /! _ - <br /> ccNTRACTDR IL'1' L C_ �/ <br /> PHONE <br /> BUEE CONTRACTOR AtN»0 Sr._, ' r`<� , /y�, �� ....-`1JC7 .;,.; Al <br /> �. 14KTNE F Lf���'. <br /> i <br /> fAHIN1i 9p LICE RIONE Y <br /> 1 F MP !❑NONVVELL ❑FIEPLACEMfNT WELL 0 MONITOKNG WTIL f <br /> t <br /> {[{[{[1 J INWALLI7NIN ❑WELL RVSTEM REPMN ❑'ROBS-ONNfCT PEPAM ❑VAPOR EXTRACTION WELL <br /> ❑Nwv ORrl�r ;T.P. C.fPT11 <br /> PUMP&FT rT- 0 <br /> � <br /> RYR O:PIM'! TIRaT.WATER[FULL <br /> 13 OUT-OF-SERVICE WELL D OEORIY&KAL WELL a � <br /> r-r/ ❑ 601L BORING B <br /> aTnucrKTN: I c 1•>'-�]�AI 'IFC _LL 1 //--7 <br /> SI YPE Of W CON6CG0 INDUSTRIAL- FT -! <br /> �t APTTOM dA.OFWIIlIXCiAVATTON^Sfr OIA.OFCONDUCTORCASNO `. <br /> (3 DOMISTICMNVATE ❑DRAWL PACKMZE TYPE OF CASINGISTEFL/PVC 1 <br /> ❑NMIGIIIUNKA'ALDIA.OF WELL CASINO D <br /> �f[!aW?N DEPTH OF GROUT SEAL f1PEUFKA7)ON _ <br />} D NW40ATICWAG Comm GROUT SEAL aT6rMLID SY`��-�• - � — E <br /> h C"OUT 11"NO NAME ffff <br /> ❑AoX.IMPT H GROUT SEAL Pl1MPfD:O Yw ❑Na <br /> r ! GGNGAETIPEGIaTALernruu.ER:©reF ❑He <br /> ATIN6DIE.DOTH 3(I y LOPING CHIiTER SOX/arOVE RPF s <br /> FROF.Gm CONSTMX"ON/DLSUFNO SIISTNOD: MUD ROTARY _AIR ROTARY AUGER CABLE <br /> OTHER <br />' 1 HE"I'Elr CERTIFY THAT t HAVE NIEPAREO THIS APPUCAI 10N AND THAT THE WON.WI - <br /> LL sf DOME IN ACCORDANCE WY17H SAN.10AWIN COUNTY <br /> OROINANCE6,STATE LAWS,Mal RULES <br /> REOIRATIONS IIF THE 6AN JOAOVtN COUII!-Y, NOME OWVHER OR LICENSED AT.EM's SILENATufF C[RTFFIF6 TNI FOIIOWTNO:•I CERTIFV THAT IN THE PEAFOISAANCE OF THE WOfW WR WHICH(�t <br /> TMa""AfT ISISSUED,l6NALL NOT EMPLOY PERSONS BUaLICT TO WORIIMAN'6 COMPOl6ATION LAWS OF CALIFORNIA.• CONTRACT'OR'S HIRMC OR SUBCONTRACTING BfoFT/LYUIE CLRTMIEs J <br /> THE FOLLOWRTO: •t CERTIFY TEAT IN THE PERFORMANCE OF TNI WOIFC FOR WHK:H THIS PENJIT IS IBSUEC I SNAIL EMR OY PERSONS 8URfECT TO MOfI61yAN'S COM010M A UPIE IUrr OF <br /> CALLpD11N1A > -{R{i{F C }I HDyti AOy E ALL �/1INJ6/�;TION6/AT 1210e,4Md623. COMR•ETE DRAWINO AT LOWER AREA M VIOED. <br /> 81FN.S K-- - {-� ,.../ , <br /> f11aT F`AAN IDEM Ie se.i.l Sew •t0 <br /> 1. NAMES OF aTR[ETB OR hDAD6 NEMIa!TO OR BOUNOfNO THE PROPERTY. A. LOCATION OF HOUSE SIWAOE D(SPOSAL 4YTEM OR PF1OF•0rlE4 <br /> 2.OUTLINE OF THE PROPERTY.GIVING OPAWSIONS AND NORTH DIRECTION.OU <br /> 3,DEXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> IMEFLSTOIE.D TEINfS AND LOCATION OF ML EIUQTtfW AND PTIOROSEb 6. LOCATION DF WELLS WITHIN AADRIS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,MlCLIIDIND COVERED AREAS SIKH AS PATIOS.DNVIVMYS,AND WALKS, ON THE PROPERTY OR AD)OIIWNO PROPERTY ' <br /> Ir T'CS !4,I(=1-1- ;v 300 } F=ry`,T.>>F11�r� <br /> 1 <br /> PAYMENT <br /> JUN 1793 <br /> _ p BlWl.i(1t�UUr1 ~r- <br /> CIC Y <br /> II. tAIV! HEAL rH SEAVr !'C f I �' <br /> R( NMlN7-TUNE r GE I l <br /> WARTMENT USE ONLY '• - —r k <br /> AFpINWNn A..FFFIFe ay LC <br /> a'", -t—jff 4 O.I. y`l •,(5 IMnp Inwa—ST n.t. <br /> Dr.Vls ,hit.—11v O.t. .... <br /> l_ t <br /> h <br /> ACCOUNTIIN7 olltr: MOI Fwc■ �- - <br /> Pf CODTA FEY Rio AMOUNT RIAiITTIOD C C ICALN RECOVm■r DATE ' <br /> FIMITI6FTMCE REQUCif M17WIpI INYGICE - <br /> J � �l. - �'7 1�•��� i <br /> } <br />