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APPLICATION FOR WELLIP+"EMP PERF' <br /> SA,..EOAQUIN COUNTY PUBLIC' LTH Si .-!_ICES <br /> ENVIRONMENTAL HE DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> f <br /> NPN-REFUNDABLE PERMIT EXPIRES I YEAR 1`110101 DATF ISSLED <br /> I <br /> � ICBmpled In IrIEtlka.) I <br /> APF'LtCAVON IB IIERE RY MADE TO TrIC CMI JOAOVIN COUNTY EOR A TT.N.111 TO CONSMUCT ANDMn UISrALL TIIE WOLYE UESCRIBEO.IIITS Arf'LICATION 16 MADE IN COMPLIANCE WfTN BAN <br /> JOAOVIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 MID ME STANOAN18 Of SAN JOADVIN COUNTY I-VBLIC TIE ALL It 8EnV10EE,EfN TIONNIEUTAL IPCALTH 13IVi61ON_ I <br /> '.JOB AODREGIVOn ATN► ;- crrr rn <br /> C;-'. :.-' i :r,f _ ' <br /> - - - _ - PARCEL slzunrtfl <br /> OWNER-S NAME ///� C/,!.i_-' %✓�".J'' _ ,%:,•.; _. ADOr1ESY <br /> 0 ITAACPoT �(.�:J''-f t_,-( -- ADOREOs.---:�": •'/.l'-,-.. ucE ri1011E1 <br /> ..�� :- <br /> BVS CONTRA <br /> CTon /rl.1 '1 'r:r. ADOREOB /::-'f•-":-, <br /> TYP1EPaFwEtMVPd }❑fiEW WELL 111 RErT.ACLMEfIT WELL ❑ MOIIITORINO WELL/ ❑-I RA <br /> OTIfLR <br /> ry . <br /> 1L�--J-�I INSTALLATION y WELL SYSTEM REI' n ❑CRORS-CONNECT REPAIR I <br /> LJ VAPOR EXTCTION WELL f J <br /> LJ Newt R-11 1LP, DEPT II PUMP SET_ET, FIRST WATER LEVEL a <br /> HY►E OF RUMP! TT----TT Py �. <br /> 0 OUT-OE-SEnVICE WELL U OEON IYGICAL WELL I L'l!GOIL OOMNO S <br /> INTENDED USE WELL 1I YPE OF WECONSTANCIION SPECIFICATIONS A <br /> ❑INOUSTNIAL ❑OPEN BOTTOM Otk OF VKLL EXCAVATION DIA,OF CONOVCIOR CADIIIO 0 <br /> ❑DOMEBTICTEVVATE ❑OEXAVEL PACKFSITS TYPE OF CADINOI6TEEL,PVC DIA-OF WELL CASINO 0 <br /> ❑RUBLIClMUNICIPAL ❑DRIVEN 017"11 OF 011OUT DEAL 6PECIr(CATION R <br /> ❑I"R10AT1ONfA0 110711 ER MOOT SEAL INSTALLED BY GAGUT RRANO NAKIF, <br /> '❑MONITONNO / GIIOVT SEAL PVM rto:❑Y. C3 Ii,, CO1JCIlETF r'((ICOIAI nY ONLL[14❑V. ❑Ne S <br /> APRIO X.DW"I S�Ci LOCKIIlO[NESTER BOX1616VE rTIY S <br /> PROMISED CONS rRVC NONfDmLUNn METHOD: MLAO 1101Mv AIR norARY AVGEn CABLE 01 HER <br /> I HEREBY CEnTIFY THAT L IIAVE PREPARfO 71119 A11UCAIIOII AIID THAT UIE LY M WILL BE DONE f71 ACCORDANCE WIT IF SAIL JOACUII;COUNTY OMOIANCES,STATE LAMP.AND nULES N40 <br /> MODULTION9 OF Tltt DAN POADUIPf COVffrY-110LIE OV-Eft OR UCENGTO Aa EICI•R 610tIATunC CEnrIFIEC T TIE fOLLOLNWM'I CtEff—THAT IN THE/'LIIEORIAANCE OF TIIE WOW EOR MUCIC <br /> THIS r'EPAUT IS I&SUEO,1 BItALL NOT EMPLOY ITF193+10 GU5J[CT 10 WOnKMAN'S COMfYNSATION LAWS OF CAL11'"PtIA CONTnAC7011'0 IIIFVNO On GUB-CO11TRACTINO SIONATURE CER11r1EB <br /> L THE rouow NaT -1 CERTIFY THAT D!TIIE 1Ynre Rl.lA110E OF ELIC Won""FOn Vn11CII 11118 MRMET IB ISSUED,I PIIALL EMPLOY RRE01M BLIBJ[CT 10 WOnKMAN'S comr fArin"LAWS Or ; <br /> CALITORNIA.'_T_frE.SLpmc.Kt MV//Sr,CA LL 24 1Mlllr IN ADVANCE FOB ALL Rta UIn ER I—Ec Tin Hf AT 11001 4ee-11421. COMMZIE DAAVn11a AT LOWER AREA PRO"0170. <br /> 810nfd X /L, 7111• <br /> ROT PLAN IDI«r fo N,pu Rc.b <br /> 1. NAMEB OT STME19 OR ROADS f7EAREST TO On nOVNNItin T11E FT10RREl. 1, LOCAIID1t OF IMV9C p(WAOE OI pfv BA1 EY6TEM RR iTIOIO DEO <br /> 2.OUTLINE Of TIIE IT10rEnTY,aneva DIMCNFIOrIB AIID NDn111 DIRECITDSEW <br /> AOC CXPANSID1f OF 9EAOE DIOPOBAL pYfiICM9, E <br /> 3. NMENSIOWO OVIL11fF0 AND LOCATION OF ALL EXIRTIIIB AILD 1•f1RPG6rU 6, LOCATION OF vaElA6 w1T 4nW MONS OF ONE 1 JNOnED ruC P'f. <br /> 6TRVCTVnrH,RICLUDINOCOVEIIE111 AREAS'SOCIC AS PAI 106,DRIVEWAYS.AID WALYSR Ott TliEf o MsrY On AUJDViwo,RarC". <br /> .....v......:.....G......�-... i..-.. <br /> t ... <br /> .. ..r .. <br /> 1 <br /> ., y..... .., x. 1 <br /> 3- <br /> u� <br /> 1 198 r <br /> INC.,... ' <br /> KI IN C <br /> -- <br /> I <br /> X <br /> 1 <br /> .....E......t.....,i.. <br /> i <br /> .....�. - ....r.....E......<-.....i.......... , <br /> ...:....:.:......:. <br /> 4 <br /> z <br /> I <br /> :.. .s.... :.... ....... <br /> .. ... <br /> ... <br /> .....; <br /> 4 <br /> ......E. <br /> j .. <br /> . <br /> i <br /> ..... . E.....E <br /> ' " . <br /> n....".... .... F`.":. <br /> OFPMIIMENT USE ONLY <br /> APPnFIIIPn AeelgleA bT Ef-rf..r.:•.r' f':''�s O.n !f 1 -/�J_ r/cM.. -'J 71�o i <br /> OItwR lrnpea[IeP er Dile ILInP In.peellon RY D.Ie <br /> DeF1n.ellen InFreRsn DY O.le <br /> cenllfwlnrt /d.nA �i'o• � / r/f /` ,� / r, -1-- <br /> AOCOUHIINO OHLYS 10711► EAC► <br /> ' ►E COb[B IEE INTO AMOUNT RTJAlll EO CNECK►rCAill RECEIVED SY DATE ►PIMITfSE71vTbE nE01l[ST NUMBER INVOICE <br /> Pub.Health Sam-EmAro,173(1197) <br />