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APPLICATION FOR WF.LLIPUMP PERMIT <br /> SAN JOAOOIN COUNTY PUBLIC HEALTH SERVICES \� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209)4993420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I <br /> APPLICATION IR HFAE fly MADE TO THE RAN JOAQUIN COUNTY Fon A TERMrI'TO CONATFRICTAUD O"INRTAIL THE WOW orscifeEO.71118 APPLICATION 18 MADE IN COMPLIANCE WIIN RAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE RtANOAADO OF RANJOAQUIN COUNTY PUBLIC ITEALLTII SERV`/ICES.ENVInONMENTAL HEALTH IHVIPR)N. <br /> JOB AODREBA/on APNI AC)Q� A1o14-�h WI'jSIje) kkl CITY-. STC(-A • O(v <br /> //�I c 1 PARCEL RqF/AI'NI <br /> OWNER ,�F7'S NAMF • .3�n AnnnFRP <br /> ��(1hI-h_/� �Q F7_Cx �!) �� Q3Z <br /> mo—_— MIONE F�z.J <br /> colnucion_/��LJAtvClA �P �nVirr.11MPnrh�J� AnnnFRAJflo3 Lv_/MAALW[y, LreE O1-7-7n1oNE► A o26y <br /> OUR COW RACTOn �.nui"OPT"I>Ir AnnnEne (5 MiAt.l..•..(-► 117 �f 22 ' f7 <br /> _ � G T n1oNEf ti 7t714 <br /> TYPE OFWELUPII_ M,P• ❑NEW WELL ❑nEELACF.MF.N7 WELL ❑mo—non—Nn WELL/ ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM IMPAIR ❑CRORA CONNFCT WrAIn ❑VAPOn ExtMCTION WEU/ <br /> _ ❑N.w❑Tl.Pdr H.P. DFPt 11 rump AF.TFT, FInRT WATFn LEVEL _ <br /> N V1'E Of MMPI ` O <br /> ❑ <br /> ❑OESTnVCT10N: OVt-OF pEnvtu WELL ❑OEOPIIYAICAL WFIL/ 04 FOR.ROnINO / <br /> 8 <br /> INTENDED I/iE TIME Of WE CONl1nUCliaii iVECIfICATIONi - - <br /> ❑INDUSTRIAL ❑OIEN AOT70M CIA.or WF.IL EXCAVATIONN <br /> _p� DIA.Or CONOUCTon CASINO/ /& <br /> ❑OOMFRTIC/PnIVATE ❑OnAVFL PACK/SI;E TYPF OF CA9I0,01/911'r1/PVC I. OTA.OF VW.1L CASINO <br /> ❑MIRIIC/MNNICIPAL n Wit -T'� ��� 0 O <br /> PIP nfl•Ill OT onolll SEAL TQ4(,l h RrECNICATION <br /> ❑IRMDATKIN/AO ❑OTIoR R <br /> p� OAo11T SUI.INpiAI l FD BYH �7'AEMI Ono11T BRAND NAME -I G D T-01)r E <br /> AP R ONITOAINO ^r OInl/T AfAI A/MIEn;❑Vr��.Ne CONCRETE PEDESTAL RY f)NLLER:jRY•• [IN. S <br /> PROPOS.DEPTH Lc�! LOCKING CowarEn ROXJRIOVF.PIPE IV 10-PROPOSED CONSTRIICTIONA7PotUN0 METHOD:MUD ROTARY / $ <br /> Aln 1MTARY SLIDER CASTE {p p/QO�� <br /> OillEn �O <br /> 1 HE9E RY CEATtrY THAT I HAVE rnFPAnEO THIS APPLICAl1ON AND THAT IIIF WnrW WILL RE DONE IN ACCOMANCE WNI/RAN JOAOVIN COU MY ORbINANCEB,STATE UWR,AND RULER ANO <br /> nEOfit.AT10NA OF 711E RAN JOAQUIN COUNTY,/TOME bWNF.n On LICF.NAfD Anr..NT'R PIn11ATUnF CU/Ir1Ep Tiff rOtLOWINO:'1 CrMIrY THAT INT/IE PtnTOnMANCE OF TIIF Wolff FOn 1c <br /> lilt" <br /> TIROITn%RT IR IAAIIfn,I P11A1L Not EMM OY TEnRJINO RtIRJFCT TO WDAKMAN'P COMPFNsAlION 1 Awn OF CAttrOCHIA.'CONTRACTOR'a HICIN0 OA PUR CON/MCTINO RIONATFIX CERTIFIER <br /> //1F FOItOW1NA: t CFRIIfY TIIAT IN TIIF PEnfORMANCE OF Fitt WonX Fon EMIIcII 11118 MnMIt IP IRSUFO,1 PIMLL FMPLOY rEnRONR OunJF.CT 10 WORNMANY COMIENAPHON UWA Df <br /> C_.4At.trIT 1A.• titt APPLICANT MUST CALL i�11DUgi ANCf fon ALL REOUDFO IN <br /> �-MrION4 AT 1}op)440 N,3.COMfLE7E DRAWINO AT LOWER ASIA PROVAND. <br /> RIfnM x 1/Hl rl, <br /> MOT PUN lo—Is 9,0.1 1tn.1• •is <br /> 1.NAMES OF PTREETR OR ROADS NfARERT TO On ROUNDING 711E r"oKnTY. <br /> !.OUTLINE.OF')IF PnOPFMV-OIVINO DIMFNSIONR AND NORIN DInFCT1on. S.LOCATION OF 11098E BFWAOE DIAr IIAI RYBTEM on P/KIrT)REO <br /> 3.OIMFNRMNFn OVltINFn AND LOCATION or ALL EXIRTINO ANn PooPORF.D EXPANSION Or PEWAOF.DIOMPAL RYR7EMO. <br /> Bt RVCTURER,INCLUbINO COVERED AIIEAR SUCH AR PATIOS,bRIVEWAye,AND WAtKP, i•LOCATION OF WFILS WIIIRN nADIVR OF ONE Nt1NDntn ruly fT. <br /> ON TIIF I SOPERTY OR ADJOININO MIDIEntY. <br /> ................. <br /> DEPARTMENT URE ONLY <br /> 7A--t'A RY { Ars. <br /> Dsls✓ Pune In•nlnli.n Ay <br /> bets <br /> D+•Inntlen IrwnsetMn Ay <br /> D•t• <br /> Cemm.r.l•: <br /> ACCOIINTINO ONLY: -- AIDS FAC* <br /> PE COOFS rtr INFO AMOUNT RtM11ito CIIEC ASII RECDVEb AY DATE <br /> PFNMIT1111MVICE REOUtiT Nt"Ren INVOICE <br /> Pub.Health Sere,-Enviro.173(3/96) <br />