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APPLICATION FOR WELL PU114P PTRM17IT �.c, PAYMENT <br /> SAN JOAQUIN COUNTY PURLW HEALTH SERVICES l RECEIVED <br /> ENVIRONMENTAL HEAL R DIVISION <br /> P.O,13OX 398,304 EASTwmER AVE UE,STOCKTON,CA ami mJUN 0 6 1997 <br /> (209)409.34 0 <br /> NOR-REFUNDABLE PERMIT EXPIRES I EAR FBDM DATE ISSUED rusuCHF HSERviAN JOAOUIN c S <br /> ItIlmpfft+la TI nivj_ ENYIRONMENFAL HEALTH DiVISION <br /> APPLICAI ION In IfFnE BY MAOt TO TIIE MAN JOAOUIN COUNTY FOR A r[RMIf TO CONSTRUCT ANOm OtR left THF.4YOIEC ryEFCR1aE0.1fnS A <br /> JOAOmN COUNTY OEVELOFMFNT TDLt,CIIAPTEn B-i f 5.3 AND i1tE gTANDAaUA OF aAN JOAOUIIt OVNTY IT1n1,fC IIEAL711 6EAVICES,ENVl11pNR EMhtT6fEAt7 1 UDRFION,IANCt Wlrlf SAN <br /> Jon ADORERRR/n APNI V1411 I V� <br /> CfFr r'AnCEI rZElnnTS <br /> mvT+En'e NAME GfJ9M 1� (3 4'! <br /> A <br /> Nn1+EPa <br /> _ P.-77-49 9CotrtMCTOn nF.na +Ct/� /I�ZF^� 1yFy ', TL2FYJLtIJyjP 0 NEW WELL 1I RFr-LACrmEw WEIL d MIRlaTA1.L 1T101T0 YYELL MYSIPM REPAIR 1,CnOPP CONIIEC I+IrAIR 1r <br /> Nnv❑ VArOn F%TMC. .—LL N { <br /> IW'•h IT.P, DErIll IM11Mr RET FT, FIRST WATER LEVEL <br /> N YI'E of IVMri d <br /> 1 ❑OUT-Or nTnVICF WELL ❑OEOrIlYPICAL ELL 1 r-� ^" <br /> gtlR 00RINp A <br /> 4 Ir-NyyIENDEO V6E 1tT--Vr E OF WEL CORS 7nl1C�-TION SPE - <br /> { 0INIMIN I RIAL 0O1T.N nnrTDM DIA,OF WELL TRC.AVATIRN <br /> I 13 DOMESTICATSVATE Caorr"VEL 1'ACNINt;E VIA.Or CONDUCTOR CAPRNI O <br /> .I TYPE hT ChRINO/Mtf E1nNC <br /> II <br /> DIA.OF YIEtL CANING n <br /> tVRLICIMUt11ClFAL ❑OmVEN nErTll OF RROIIT Sfht <br /> .I r-I RI lc,runAT,ON A <br /> �.� '�+� GROUT nRANO NAME <br /> ❑IRRMAl10N/AO LJ OiliEn ORUUT SEAL a+gT Al1EO MY <br /> APmo MTORT t1 1 OMoUI REAL 1RIMIYn; Yr I/^ CONCnETE rrQtnTAL MY ONO kF,n; y lJ M. <br /> S <br /> ArtTDk,OFRTII r LOCkINO CIIF.PIER A k/PtOVE,r1rE <br /> ITIOrOSEo CONN r11UC TIo NRAgi LINO MLYNO01 MUO IIOTAAY B <br /> hin IMTAnY A1MEn CABLE <br /> DYIIEn <br /> f 11MAYf CERTIFY T11Af ITIIA{I HAVE i`REPARKV TNIB AMLICAIRIN AND INAT TI IF WOM WILL RE VONE IN AC ORIMNCE WITH BAN JOAOUIN COUNTY OnryINANCEp,R7 ATE[AWS.ANO RUEEB ANO <br /> n0til-ALIO Nn OF INE RAN JOAOVIN COUNTY,HOME OWNEn On LICENS{O A(RITI'R BIONAtUnE CETNttI B lllF TOLLOWINp;'1 CF.RTII'Y fHAT IN TIRE 1'FfRORMAIIEE OF TIIE WOM ronYtllR:/1 <br /> Titt r Ll nv 7R TNPUEO,1 SNM.t NOT EVTOW RERSONB rE or T TO WOW MAN'y COMT'ENNATION tnWS F CALNOONrA.' CONtMCTOR"g IfI11fNO On PUS-CQNTIµETI1M SIONAf URE CIRIIr1E8 <br /> TUE rOLLO1MNp; •t CERTIFY THAT IN THE r'ERFORMAHCE OF T11E YYp Rk toR WIUCII TIPn rr"mm Ig IR R;D,T gllnlf EMrLOY FERpONg PITRJECT TO WORSMAN't COMPENSATION UWS OR <br /> COPAri CALIIORIPA,' TIIE A CART MUST CAL4�1 1 IN ADVANCE FOR ALL REOGRER,INS Tfo AT oI•Ra'AtL F rLOY EI MIT O"S AU O AT LOWEn AREA R'S CO{O, <br /> glSr.•,!k � �G..� <br /> O•Is <br /> 1,NAM{R OF BTREETg OR RIOT KAN IDr•w le PaN.I RnaN 'lv <br /> ROAbg NEhRERT TO OR ROV MO TI E,rDCI3OM,- a. LOCA710H QF IIOVaF REWAOE DIBrODAt AYRTFM On rmrOgED <br /> 2.QVTUIR:OR tlfE morERTY,Q1vTNp OIMENRfONR ANU NQrtEI!DIRECIfON, <br /> O.bIIAENRmmw OmiUMR ANO tOCATNIN OF ALL EkIRTIIM ANU rTNTPOREO EAPANRION OR SFWAOE Otnr'OBAL gYeTFMB, <br /> ig1nVCTtlntS.INCLUDING Co VEREV ARIAS SUCK AS rAIfOS,OIRVEWAYR,AM WALk V. R•tOCAt10N OF WELLS YA110N RAnIUS OF ONE 11UNtlIrfO tn-TY Ft. <br /> ON tilt PROrERTY Olt ADJOINING r110r[RrY, <br /> . <br /> _ _ .. .,, <br /> -. .. .. <br /> .. ..., ;-PAIFMENT <br /> "REC <br /> D <br /> . . J <br /> �.1:997 <br /> - ... $AN JOAOIiIH CPtINTY <br /> PUBI:IC HEALTH SERVICES <br /> - ENVIEiONMENTALHEALTH DNiS;CN <br /> 1 <br /> -... . ... ..... <br /> I OErMTMOIT USE ONLY <br /> ARARa•Ilan AeR,gS•A RY � b•1. // �[ 7 <br /> F7 <br /> A,.. <br /> G,P,A T+>mE'— <br /> T ; s <br /> � N..1.,:r;en In•w+nen Rr 'Y� O•r <br /> , CP�.rmdq• � 1.1 0.1. <br /> Ac—lpNQ ONLY; AIIMF nc�i <br /> r[COQER fIr INTO AMOUNT REMIT I ED CIItCI(EICARN RECOVEtl BY COATI: YOVAIT/EEAVICE REOUFST HUMBER INVOICE <br /> 'PDI).HOnMil Sgrv:-Gnviro,C/3(311963) i <br /> S <br />