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` T APPLICATION FOR WELLIPUMP PERMIT <br /> �sAN JOAQUIN COUNTY PUBLIC HEALTH SERVIIY <br /> ENVIRONMENTAL HEALTH DIVISION \1 <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> 12091469-3420 <br /> ROI!-RUVROARLE PERMIT EXPIRES 1 TEAR FROM BATE ISSUED <br /> ANNICAT IEIN In PRAT MY MAOE TO 1NE RAN.NIAWAN COUNTY Inn A PFRMII TO mRSTMICTIAImmn INSTMt WM WOM DFRCRIRFD.TNR AEYI ICATION IS MA <br /> JOAOINN COUNTY DEVELOrMFNT TfrLF.,CIIAPTEn 9/-.1X116.3 Arm t?M ITANOAnOn OF RAN.1OAOUIN COUNTY Nj,,ALIC IIEAytm/EHVICER,ENVIOGNMENTAL nFALT 1 DIVISIIN COPAN ON. VrtTII EAN <br /> JOR ADryRERR1TIR AI`N/ /47-1 �R OOf[J I Vl (CJ CK E—0J✓ PARCEL RILEIAPN► � (Af M( <br /> b� <br /> cirr <br /> OWNEn'RNAMF -MO[ ON (1/v r-1,S d-c#aiL DUrPj, 14� F-t. 0 � V� /1Q El-� <br /> CONT MCTOO_ <br /> F�1�- T�/ Jg'18 ��" � AOORERR ATONE r TiL <br /> ��LL �(. FLc.SB 00£i ArO.. � 7Js <br /> RUN CONTRACTOR r'�' Q I C/r OAI <br /> ' AntN1F,R! <br /> tIC• AIDNF./ <br /> TYPEOF WELLIPVNW: ❑TIETY WELL 11REAACTMFNT WEIL ❑MONTnnINO WFtt. ❑OTHER - <br /> ❑INRTALtATION ❑Wttt/YS,EM REPAIR El CRORB-CONWCT REPAIR ❑VAPOR 111I..TIOH WCL P <br /> ❑New❑rL..x H.P. <br /> R YP[OF AfMFI bETTH ATMP NET_PT, FMRT WATER LFV(E^L <br /> ❑❑ OVT-OF-SERVICE WELL ❑OEOAIYR1CAt WELL T -1 BORING�1 f� !1 GI & O <br /> / n eE/IllvcnOH: �a� C PrGr+ <br /> Nt ENDED U! YPEOF E t0 ST0.11C TION PECIFICATID ■ <br /> ❑iNIRESTAAI ❑Orem ROITOM IIA.OP WEILE%CAVATIONYy A <br /> l--� IIA.OF CONDUCTOR CASIrro <br /> 1J SOME-RTIC1Pn VATS ❑ORAVIL PACK1Sttt TVI'(OF CARIN111RTEfRX'VC <br /> ❑rumuc A unirp'AL ❑MVEN VIA.tr AT, CCASINOO <br /> R <br /> pEFf11 OF GROUT REAL //'ECRFeCATgN <br /> ❑IRRIMAVOWAG ❑OIIRRR <br /> R0.0Ur REAL INRTAI.LFO NY 011018 NnAND NAME Q <br /> ❑MONITONNMI OTIn10T!FAL rUJJ"O:©Yr I]No CONCRET F <br /> E P[DE/TAI.BY OSTLER:❑Yr ❑Ne S <br /> APPROX.or."" tOCKINp CIDSTEn ROXRROVE AR <br /> 5 <br /> PROMSCIP CONSTRIACTIONtMEUNG MEINOo; MM ROIA"YAIR RDTARY RUIN Rm--CANLk _OTiFEril�-16 � <br /> 1 iIERFRy CFnrIrV 71147 1 HAVE AIEPA11F,0 EIRE ATT4N;AltoN ANO TItATMOI111E WOISt RAH_NE IgNE NT ACCOMANCE WITH RAN JOAOUm COUNTY OTEIINANC[/.S/ATE kAWR,ANO MII FR AtIR <br /> ViNg MOroNR OT THE RAH AI IL N)OAOOT <br /> COUNTY.RIME OWNEn T o WOR[O AGENT'!SM"AI URF.CEnTD1E/TIE rOLLOWOTO:'t CEPOIFY THAT.Nt TIIE FTWO1MAANCE OF TIM WOIK FOR NRRCIf <br /> 1{RS ITIOAII IR IRSULO,1X1141.1 NnT EMPLOY I4RRONS SlR11ECT TO WpARM AWN COMPENSATION tAW9 OF CALnORMA,•CONIRACTOR'R INRIND OR RUS,COtfthACTINp RIORAWnE Ct11TtrRR <br /> 111E rOIIOWIFM: -I Ct:RTIFY THAT OI TIIE rERr0F#AAIR:F Of Tiff Wum FOR MAOcII Tt"l TEPATIT IS ISSUED,I RI1ALL EMROY 11:nRONN CT TO W011101TAN'■ <br /> CAUFOTMRA.• FIE A t MV T CALL.-4"Dung IN ADVANCE FOR RLL REMItSRtO T! RIlsJ( COM1'ElllAnpN LAWS TIF <br /> PECT/0 AT 170/14"4411.COMPLETE b1UWNN1 AT LOWER AREA rnOVIVFn. <br /> mwMA x <br /> n.I. <br /> ROT FUME Rh.w to/Ed.,Sed. •t. <br /> 1.NAMFR DF RIREFIS DR EIeApR NENIEST lD On Fot*rmNG TIME PRprERTY. <br /> OlnttIM Of TItt It-tOCATtpN Of IroVRE SEWAGE g1Srp/M SYRTEM OR PT10tOSED <br /> 2- YIOIFRfy.OIVINO DIIAFHRIONS AND NOin 11 ptnEeMN. <br /> bEIIPAHRIOH OF SEWAGE CORPORAL/YSiF.M/. <br /> ]. RATN1ROtRED alrrtRKS AND IOCATNIN OE All PRINTING ANh AIOI'ORFry /.LOCATION A <br /> OP WFILS WRN MON/OF ONE IM"ORED rNTY ff. <br /> STRUCTURES,INCLUDING COVERED AREA/RUrC^H A/PATIO/,DFLVEWAYS,AND WALKS. ON Tr1E FROPERFy On ADjoRM M FROPERFY- <br /> st t ��acf rd l�rG�u�l1 <br /> VEFAATMFNT USE ONLY '��]7 <br /> APPIIe•t1+.n A—,,,RY b.l.v• f2-' Mu <br /> O.ou1 B+4Rrn.n Sr Dore f%—P I.bbMen RY DR. <br /> Ore.,�el.n IrnP.'tlon pr <br /> D.M. <br /> C.mm...�.:�r.v+lt LS ue.,d GondLhu,.,� d�-94{..+� 1✓1 PI+Sf�j cari¢s,pbrlq(QyLE� J ��z•�' <br /> LACCOUNTINO ONLY: AID/ FACT <br /> PE CODES FEE INTO AMOUNT REMIT IED CIFECKSMA611 nscmeO SY DAZE ►ETNIIT/S EAVICE nEQt/E!T IIUMN9i <br /> INVOICE <br /> Pub.HGRhh SeWL-Emlrp.173(3196) <br />