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•APPLICATION FOR WELLIPUMP PERMIT <br /> UOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NON-REFUNOASEE PERMIT EXPIRES I YEAR FROM GATE ISSUER <br /> AFELCAMNIBI1EFESYMADETOTMERANJOAOVIN COUNTTFOnA (C.-PI.UIIn TrbIIF•lel <br /> JOAOUIN COUNry DEMO"W TITLE.CHAPTER 9- FfWE1i TO CON9lnUCT ANURIA IN6GLL THE WOW DESCRIBED.TIRE ATPI.ICATION 19 <br /> 111 R.3 AM TIE STANDARDS OF BµJOAOOWCOUNTYml`JC IEALTN.1,WCia.ENNFO MEWAL HEREIN OM610x.E IN N2E WAII enN <br /> Joe Aoon[etRIR Am• SI SI P/7G IF=/C <br /> AVL-YVE DITr STpdY'lYJ/E( <br /> awWEB xMIE C /1/.JG_9ry'A/ G f 'cfvnpCEt el$F/AmF /O g-•/G2f-G/ <br /> CDWRACTOA e <br /> CGAAp.0 n/=tt / ADOAEBt S%•FAyE As ja y' mOM.,Z`J <br /> AVc. ADORER.7t/z 51 E. c''i14-L+rP LR:F37/S�o `f•3a3s- <br /> SUBCONTRACTOR ;;i l��lvly fNpNf[AryLJs 7k, <br /> ADDRESS <br /> �--�• EArx[E <br /> }YPP Op WEL.+ ❑NAW WELT, ❑"F{ACEMfW WELL <br /> ❑ <br /> �❑MM�Mµ PUMP., <br /> NWEµF OFFER <br /> INSTALLATION WELL SYSTEM AFpAIq ❑OF...CIAOECTEpgp VAPU <br /> RYOFMMPI H,P. <br /> q FATMCTbN WyLLf <br /> Df PTN mMP SEi�FT. <br /> FlptT WATER LFVEI <br /> ❑OIRg0.BFFVICE WELL 'O <br /> ❑OEOg1Y61CAL WfLL F , 600..OmN0 TEST .e//V< <br /> ❑DfBi11VCT10 N: IT <br /> SV <br /> IHIENRED Vhf iYFE OF WELL <br /> ❑INDUSTRIAL EONOF WELLENCAECIFICAIION• <br /> A❑OPEN BOROM DIA.OWELL FACAVA}ION <br /> ❑COME9TICMOVw}E ❑OMVEL PAGk/BI$FDIA.Of CONDUCTOR CASINGb <br /> ❑gRVCRAVNICIPALDAWN T OFC-MM/6TEELTVC DIA,OF WELL CASAM <br /> ray MM-OF ORpUr SEAL p <br /> .-LQ IMIOAibN/AO D.T.E. MFCIf1CATION <br /> .LEI O W V!SEAL INSTALLED BY <br /> MONTIONNO <br /> -YOUR BEµP/MFEO: OPOUr.MNp NAME E <br /> APFgOC PERM E]Y: ❑N• COMM.PEDESTAL pY OnILLEq:QY. I]NF 9 <br /> LOCKM CM-TW BEkRAOW RpE <br /> MOPo•Ep CEXtTRUEHOry/M WMO MEMAN:MUD IbTARIJ <br /> AIR FpINW AUGER Cnplf <br /> ETNFfl <br /> 1115111 11, "OF1 1111, THATMJOAUAACITO TNI.AITVEwipN ANO 1NAT TNF WOPL WqL BF GO NE INACC OgpµEE&MIBAN MAi COVHIYOmINANCIA;STATE LAWS,µp MnEn AND <br /> REOLRATIOHB Of TIIF BAN JOApVIN COVNTY,NOME OWNER OR LICENSED AOFW'B p10NATVIIE CfRfIfEB TIfF iOLLOYANp:•1 CERTIFY THAT M ryE FEMOIWµCF OG ilE WOR(FOR WITCH <br /> T IRS PERMIT 19 ISSUED,I.IMLL NOT FLY fon ONE 8yR FCT TO WOgRMAMt COMFEXAADOX UWBOF CALIFOULDW COWMCIMpT ATIN OR BVp� <br /> THE FORTIA.- M 'I FIRCAN TNwi IN TIIE PEPfORMA!['f Op TM[Ynlq(FOR WMCH TME ITTAFT In ISSUED.I SHALL EMPLOY"ABpNB SUBJECT TO W OgRMAM't COMPENSATION STUB OF <br /> CµFOgl11A.• TM AFg1CANT MV•T CALL to Ib CDWOT.CO PENATION CEWe OF <br /> M• IAOVANtt OR ALL pIOUBFp IntPRROX•AI IEOII MB.NFf.COMRE![DMWINe AT LOWE1 AREA MONO <br /> BIOM F ` <br /> ilu. <br /> o� <br /> I.NAME.OF-MUSTS OR ROAD.NEAREST 10 OF <br /> "—I"THE%p1EWY~ <br /> O <br /> E.ONIIHF OF 1Hp AppEWY,pINNp DIMENpN)NA AM MAY. FICTION. •.LOCATION OF MUSE 9FWAOE DISPOSAL tYREM OA MOm6ED <br /> O. ABOUROMEO OVTLAMF AM LOCATION OF ALL EXAMING AND PDATMARD EXAF.SION OF$MADE DISPOSAL SYSTEMS, <br /> 6TNUCl Vnla.DKLUOIND COVERED APPA.SUCH A.FAME.DAA F AYS.AM WALA.. •'LOCATION OF WELLS WIT"MONS OFOM MIADRD ARTY M. <br /> ON THE gpFEWY OR ADJOUBM FROM y, <br /> S G A�-afy�i '- <br /> --.e-amt <br /> GN✓/e>iV-YCN.'-E/G, ✓J$$//O T /NC' OA>L 1J <br /> SSSS ,P P <br /> e SSSS. SSSS_: <br /> i <br /> E._ <br /> r <br /> LTPEP ONARTT u6[ENLT <br /> b 00 <br /> nron.xleR AF...I.!ay_ / _ <br /> D.I. Pm....aB. M.. <br /> C.m o.r <br /> A...DAMN.oxtr: MIO[ <br /> rncr <br /> PE CD." FEE INTO AMOUNT MUSIlle CMECxl "ECpUM,by <br /> 3SS MT pFRAIT/tNYECF W.UEtIMW.W UV.ICE <br /> Pub.Health Sem.-EDNm.173(l 7l <br />