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.t.••JLA 1 I�jll�pt ri•k`k1'� <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ; q <br /> t,•� rGr <br /> ENVIRONMENTAL_HEALTH DIVISION ,`_ <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NOMHEFUNDIIBIF PEp1A1j Ei;PIRE] 1 TEAM iI10M PATE ISSUED E ' +�J�T �►l• , <br /> IC—pI•b la Tlblklbl 1 f <br /> wPt1CA1gN N INPE SY MADE 10 111E l JOAOVIN C0UN1 RRMII COIIaTlI11::1 MU/On Nlal Alt TLIE WOW Df ILCWOfD.IVIS AR'IICAigN I!MAGE MI COMPLIANCE MITI SAN IhI 11f 1 <br /> JOAOUIN COUNTY DEVELOEYAtrlt TITLE.eNCl1APIER S 1116 AN 111E S M Al 9 OF AT JOAOUIN COUNTY PUBLIC 11FALIII SERVICES,ENVIRONMEUTA1 IIEALIN DIVISION. �I' •�lySd Yf <br /> 1 I ' <br /> Joe ADDRESSpR A,NI 3�}i NN _arv___g_poN�_PARtEI NZEIAPI/ •�,.:•y: ' ' <br /> EQVII.vN Enl e Es Po .MItlla -A, <br /> ONE <br /> 335-�ioL'7 •�: •.S <br /> OW1HR'S NAME L G wUUl1[aG K ,_.[ :t�,•jY"• . <br /> corn rNC 10R 1 L ADUfIF ee UCF MGM9 �ar..��. �•. �} <br /> IiAVSut L1'N � A ro ✓1 D E/J AL ADunEGe _ 6�1 u'ST IJCF 31-o ••YY <br /> TYPI OF WEIt/PL1MP1 ❑NEWT WELL ❑R(rtACtMENI—It ❑MUI.,IOWIIO MM1II I ❑O111ER Yt -mss <br /> I ❑WSIALlAT10N ❑WELL•Va IEMREPAIR ❑CROSS CONNECT REPAIR ❑VAPOREXIMCTLoNWfLL#-- <br /> C)—cl R—0, <br /> ❑Nwn❑l1-0, 111 ULPIII I—PetTfT. FIRST WATER LEVEL O <br /> IT YP OF PUMPI <br /> ❑O111OF GF RvICE WELL ❑OEVIY IV SIC AI MIL I yy BOIL BONr10 S ��,.T r•A�� �+C,AC'I.'µ1,��._lI <br /> M�.V+Y <br /> A E [ <br /> UNI LNDEO UGE <br /> TYPE OF W[Il - CONIIRUC ZION G1[CIFICAIIONe / . YZ <br /> ❑NHNIS1NAl ❑OI'F1I BOIIOM 01A.OF Will.EXCAVAIWN DIA.OF CONOUCIORCASING O • , <br /> ❑OOMEGIKR'RiVwi[ ❑OMVEt PAC.RRIF IVIS OF CASNIO/e1LflA'Vr. DIA.OF WELL CASINO <br /> U 1 S1 CMUN C 1 AL ❑Unv(11 ULPI II Of OIWtl1 ILL At WICOICAI ION <br /> \❑1RNOA/X,N,AG ❑OIIItR GIWUI SEAL WILL All ED BY -T E r -f tT'll� ' <br /> l$,AO,NION,q OIWUI ILEAL iVM1YU:❑Yr ❑!N CONCRETEPEOfaTALeYDNIIEN❑Y•• ❑N• J i•'S•'�V�!�f <br /> .}' <br /> APTOX.D[)1H IOCXIIIG CIIEeIlR OO%ISIUVE P{4 �'7�' B �•).,T'. <br /> PRO POGED COMSIRUC IIONIO IUMO MGIIgD: MUD ROI Ar1Y AIA/gTAny—AUOfR CASTE OTIif !.._I•-), 'Fy},� <br /> I IIEVeY CERT"TIIAf I HAVE PitEPAnED TIN!AP'l1CAIlON AND iIIAT 111E WORK WILL BE DONE 04 ACCORDANCE WITH!AN JOAOVIH COUNTY Ot PERFORMANCE <br /> STATE Tilt AND F RES AM <br /> IICN <br /> REGULATIONS OF INE SAN-A—.'Co UIITV,HOME o—Rn OR NCEIIaFO AGENT'S e10I1AIURE Cf MIMEG TRE FOLLOWING:'1 CERTIFY 1NAT 111111E PER/ORMNICE OF TLIE VA1SC FOR WIIICl/ <br /> 110!PNMT 1!ISGULO,I VIM L Not 1.MP OV PRGONe SUSJEC 110 WORXMAN'S COMPS-AVON SAW!OF CAl.WOMIA.'CDNIRACTOR'!ISIVNG OR SUB COMi1ACIING SIGNATURE CEMIFIES <br /> INE FO11 ONNq: '1 CETNY MAI IN ISH PNGRM ALICE Of INE WOIK TOR WIIICII Tllle PERMIT IS ISSUED,I SHALL EMPLOY MRSCNe•OBJECT TO WORIUTAN'S COMP(MSATION LAWS OF t •�-�l /'w <br /> M C II 110-41 1 ADVANCE FOR All.At GLAAED IN•PLCIIONsAI 110.1 AS <br /> _ S NSE.COMPETE DMWnrq AT LOWER AREA PROVIDED. <br /> CAIIFO APPLICANT MUG ILVb }t'iyt},� <br /> 1q/C / M� W <br /> alp•..AX K K� TNI• A/{/C, O.1• :'j��Sii7 k'I� <br /> PFe/V� <br /> 1 eIREFI NJ NEAn of to o .Out-l—INE PX)IFIIIy. a.tOCAMN OF MUSE SEWAGE DISPOSAL SYSTEM OR PROI'OSEO <br /> I.—LINE OF II rt RI V,GIWq UIMfNGIOIIS ANG NORM NRLCI WTI. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 1.UIMFNSglHO IN,f!AND LOCAIIOII OF AUL EXIt11Iq A ILD PRGF`OGEU !.LOCATION Of WEIIIT WTTIRN RADIUS OF ONE NUNCMD FIFTY FT. <br /> IIIRUCIUM., LUOTTO COVEIL(D AREAS SUCII AS PATIOS,UINVLWAVIL,AIR)WAIXS, ON TLIE PROPERTY On ADJOINING I'MPERfY. / I �.u ��yYY��✓✓,X��I <br /> S °E 4 <br /> sus✓ A�4e�� M�: � ��()�a• <br /> Or <br /> qA <br /> J iy C E E <br /> 3� � n" Y y�-yly?�yffe�AAJ�.A <br /> ,•� L 1\•R1�tf.`;y <br /> 1k;t <br /> Il — - �� ntrAnrmaNE Ilk <br /> U.E—1t r <br /> O.0 IL.y Lu1wUm BY D.T. <br /> �.rd f�� ' <br /> , <br /> ACCOlN1 LINO OMI I: AIDE LACI '�1LS• \- <br /> 'y �\ FIE AMOUNT RU.11t. CAtIIY Alf <br /> CIIECRFI _ RECUVfO■ OP(IVAITISDINC[R[DV[ST NUMBER INVOICE <br /> PE CODES TIRO 4T. <br /> _ ;Vr ��Ed 1J <br /> `11 <br /> .w.-ErrvuD v:f llnlll �;. ra`�1t'jl�1�r f�A <br />