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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> I ( f LQ 1109-REEFUNDARLE PERMIT[Mitts I YEAR FROM OTE ISSUED <br /> "i V IGMIau IR TFIPDeatel <br /> APRICAYON Ip HERE BY MADE TO THE SAN JOAOUW COUNTY?ORA KMAIT 10 CONSTRUCT ANOXIA INSTALL"IAOPR DEFCISSEO,TINTS APPLICATOR IS MAD!IN C'OMPUANCf WTTIP IAN <br /> JOAOUIN COUNTY iIEVELO 1 169.3 AND THE STANDAADS Of IAN JOAOUIN COUNTYPPURLIC HEALTH AERVICES,ENVRIONMAENfAL NEAL711 CAVITPON. <br /> JOS ADOMNSA7R APIC` w ;Q / CITY_J �./` / PMCEL(LRE/MNI <br /> —PI'S NAMEN A001Ea[ S111 wk- <br /> CONTRACTOR AOOIES/ 242 e4 4 44 <br /> I.IOFII/ Y <br /> POS COMPACTOR ADOM" tic# RHONE r <br /> ?Y_Pt OF LMELIIRRI►: ❑TRW WELL ❑)*.PLACEMENT Wfit ❑y MOMOMNO WELL r Q O"qm <br /> ❑NSTALLATICN ❑WELL SYSTEM REPAIR d CROSS-CONNECT REPAIR ❑VAPOR EK TRACTION WELL r J <br /> 11n-0 R.A. H.P. DEMN RIM►SET FT- FIRST WATER LEM O <br /> (TYPE OF PVMR -- <br /> o 11 lQ OUTOE-RNV�ICF WELL ❑OEOPHVEICAL WRL F 13 BOIL B�OIL ON_NOuCTON. 2X ! i JA IIQN/ q r,41e <br /> INT9OWqq TY► OFW L <br /> p <br /> CONffRUC IoN SPECIFICATION& A <br /> ❑INOL/STMA1. ❑Om.BOTTOM OIA-OF WELL EXCAVATION dA.OF CONDUCTOR CASWO D <br /> ❑DOMESTICAgVAlF ❑ORAVEL PACKl9TE TYOF CASINOATEELAVC DIA.OF WELL CASINO D <br /> 11AMUCA UWWAL ❑DAMN �_ TYPE OF <br /> OF SMUT SEAL _ 9FCK2Am. R <br /> ❑VWOATONIAG ❑OTHER WOW SEAL RMAlLED BY OROUT BRAND NAME E <br /> ❑MONNTORMO MIOUT SEK A/MKO:[IV. ❑EM CONCRETE PEDESTAL BY LIFSLLTR❑Yw ❑! S <br /> APPROK.Of"N LOCKNFO CHESTER/OKRROW RPE S <br /> PROPOSIM CO MTRM TIONIOR URIO PMTHOO:MIA VOTARY__AIR ROTARY AUGER_ CANLI OTHER ` <br /> I HVWBY CERTIFY THAT 1 IIAVE PF"APIFO THIS APPLICATION ANO THAT 1'IE WORK.WRA RE DONE M ACCOMANLE MATH BAN JOACKAN COUNTY OPNYNAMCfS,STATE LAWN.AND RLAia ANO <br /> PFOLAATIONS Of TIE BAN JOAO1IN COUNTY,NOME OWNER OR LICENSED AOE W'■SIGNATURE CERTRES THE FOLLCOR"OWNO:"COR"THAT N THE <br /> P@WCFVAANCE Of THE MAK TOR"vCN <br /> TNS PERMIT N HHK",I SHALL NOT EMPLOY PERSONS SUBJECT YO MORTOPAE'S COM►MYNATFON LAW/Of CAUIM <br /> OA."aNNTR/ICTOPY N1M/0 OR SU►COMRACipA aIONATURE CORFES <br /> TILE fOLLOVANO: It C1w SNA 71E PER FOPBAAMCE Of THE WOK FOR WHICH THIS PtRMYT IS 109MU.1 SHALL EMKOV PERSONS S~CT 70 WORNMAN'S COMPHISAROM LA"OF <br /> CALIFORNIA. G NO M AUVAISCS PORI ALL RELAl11P�INS► --Al 1-1 4MJ--.CO—I dIALMIRA AT LOWE/l ATEA TOVtOCD. l I'll <br /> 01,1 R Th1._�f/?C�NC ( . --r PI L <br /> PILOT FEAR 4O.wx <br /> I.NMIES CW NTFWFTS OR ROADS NFAREST TO OR NOUfASA THE PNIDPERTY. N. LOCATION OF HOLNE SEWAOE MWOMI BYREM OR PROPOSED <br /> Z.OtlTUI[Of THE PROPERTY,OORIFO OBER 0"AND NORTH OIPECTILIPN. [RPAMMNN OOP SEWAOF DIWOVAL OVITFMS. r` <br /> ].VIMPAO ONEO OUTLINES AIA LOCATION Of ALL I10eEEN0 ATA PPIONOSEO S.LOCATION Of WELLS MATHIIN MAD"Of ONE HUNDRED FWTY FT. 1 <br /> STRUCTURM NCLMHO COVTMW AREAS SACH AN PATIOS,DRVEWAYE,APA WAIS. c ON THE IP19M REV OR ADJ090M PROPERTY. <br /> ad <br /> 0 <br /> 1� <br /> PAYMENT : <br /> JUL13 <br /> 1 - 1998 <br /> Y <br /> SAN JUA WIN CWN N <br /> - - PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMS N <br /> i I <br /> DBARTMBIT USE ONLY <br /> Z <br /> APPrMPMisI ApwR1 BTS �� 0.1.`_ /�� M. I S <br /> mwA/nPrNen eY_ D«T <br /> "—d-BY <br /> O�wu.e.lr.u.wvtlsn 6Y TMp <br /> I:rlwRriN' <br /> d� Irr>5 1<Icr �C QL' //nnyy <br /> ACCCIM71NO ONLY: NDI I. <br /> PF.COOS FFE INTO /JAOUTPT R.IlM CIEC lC AIN RECBVEO NY OAT[ P90AITNOIVTCS REOU"T nmm INVOICE 'I <br /> O 3 -TNI <br /> bt 00N3 <br /> Pub`lealth SeM.-EOVI/0.173(1N7) <br />