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P. 1 <br /> APPLICATION FOR INELUPUMP PERMIT ...r <br /> SAN JOAQUIN COUNTY PUBLIC NEALTR SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388,304 EAST WEBER AVENUE,STOCKTOR CA 95201388 <br /> (2091469-3420 <br /> SRR-REFURDARLE FERUIT EXPIRES I YEAR FROM DATE ISSUED <br /> iGmpLt.M T,616.b) <br /> AVF I ATION M MERE BY YAof TO THE SAM JOAOU COt FOR A PERCnr TO COM81 y AU MR MGTALL THE MIOIK OF6 (O.TIRR APPIK'ATroH IR MAGE M Couo, NCEµTTN SAM <br /> JOAd CO1 OEY WI WMT TR <br /> JOB AODRES&Ow A�ONI`,, TTRCRAPlER 9.1115.3 AMC)THE RTAM/OAMR OF SAN JDAM Co-. MWA,,, Ege. nEMTAIMCALTM <br /> GILW N� ia-171 IY/ 6✓ Y CRY -Tac K ,Y DmagM, <br /> PAPCEL RiZF/AaN. q <br /> owMvrB uAME//fct_y F /•71�✓ C�h <br /> coNTRACTOR /�1/f�T /7N7GN�T� D -41 AL iZ/Gi 323 r,rz M, C-D �/ 7� <br /> ApORFea srC,cc1+'•Lt rro, c.4 ,'- ,�S %IoME F S(b 72 <br /> RA CONTRACTOR ADCMICBB UCf vow.F <br /> TYPEOFWELL/pVMP- NEW L"FLL ❑ RF9V.CF.HFNT LVfLL �HONROpMO WELL/-�._ ❑ OTH[R /J <br /> ❑ MBinLLATgN ❑ WELL RT'ST PEDNR ❑ CPORS{ONMECT AWAIR r`�VAMR"TM T"M WELL C <br /> ❑Npw I]flry <br /> .,P.- DF,ITN b'.BF1-n. FIIIET WATER LEVEL p <br /> R PF OF W M% <br /> ❑ OIROFf1mCE Vhil ❑ 6i0n1YSR'K WFII s ❑ SOLL BOIRNa P <br /> ❑OERTRyCT%1N' <br /> WTENDED V" TTPE OF-cm COMCTfm"OM SPECIFTCAT1OMa n <br /> ❑ pgygTpAl, ❑OPEN DOTTOM MA,OF WELL EXCAVAMM pA.OFCONOOCTORCASINO p <br /> 0DOME9TICMRVATE ❑OMVFy PACK/ME T'S,!OCCAmrgrtREEI/AIC PA.DC WLLL CASRO p <br /> ❑ ❑pI.VEFI DEM1RN OF OMLR SEAL SC-C Amm R <br /> ❑ IRMOATIOM/M ❑/OTMER OROUT SEAL R Aum M OMUT SRAW NAMF E <br /> �MON�roRDq/4T.S+ � M-YTtt/r-noA/ OMOT REM. ,1 Om ❑Y- ❑N. COMCP{TE PETJESCAL BY O%LLER:❑Tr ❑No S <br /> APPROS-OESTN .( LobC CNERTER ROi.FTOVE qPE S <br /> ,RoMttD COMeTMUCTDWOIRLYND M NOW .. MIN ROTARY AM MT.RY A1)(-F,R CA�TNER <br /> N/t Wru r"45tTft. )dA `/ t�tovia2lxC� c✓ S 8v ' !9J [Z7 ' C� SJR 7n �' <br /> 1�SY CLRT6v TMAT I HAVE PCCPA THIS,APPLKATR]M ANO THAr TME W w k RE DOME M ACCORDANCE 4 M 9.JOAO CoU GROWAMCEe,STATE 111MO.AW RALES ANO <br /> PFO YMYRR OF TME SAN JOAp CMMEY. MOMF OWHEP OR LICEHR.O AGENT'S RMNATtME CEFRNIES THE FOLI,OWIMO:I CERT"THAT W TME PERCOINAAMCF OC TMEµ W FOR WNCN <br /> TMS,P,I MNSOET),I ,AL MOT EMPIOY PERWHB TRIRJECT TO IMO AWS COAMP ATIOM LAWS OE CAL60P.RA: CONTRACTOR'S IMNO OR eUR{OMMCTMO 6gYATURE CERTFlfR <br /> IME FO(LOLMNG: 1 CFJTTIFY TiYT M TIIE PEMORYARIDE OC THE WOIK POR NMCII TNC pEpiRr IR IRRUED,1811Afj{MPLpY nRWMR ell6)ER TO IMORIOV AM'R GONUEv.ITMR UW9 Of <br /> CAUFORMIA,' TME APMICAMT MU/STT CML"MOVPA iR AOVAIKS FOR ALL RfdO D INS.i MS AT RORI ASRY]i. COMnJrTE dUWNO AT LOWER AREA <br /> RM'-eX <br /> not%JI.,Ba-..s WNAI En.I. M <br /> 1. NAMES Of BrPEET9 OR ROADS NEAFEHT TO OR BOVNGTW THE PKHF - A. LOCATp OF COM BEWARE 0S ,R (TBTEM OR T YOGEO <br /> :. OVILME OC THE FIOPERTY.OTVRAO vfl A "V AMO MORTM d CTNM. EAPAAIBIOM OF 6 AOC OI OgAL"ST". <br /> ]. O."'SOMEO 01RUNF.S AMO LOCJLTRJM OF AU EXKTRN AW FTOMSED \- LOCAT .OP WLTLe WMIRI RAONB OF OME MUMOIRO FRT'R. <br /> ,,n,CTIRIES.INCLVDMO C,VEMb AREAS BVCM AS PATOS,fNOVELVAY9,AMO WAMS. ON THE MOPERTY ORA610eN1C0 PIOPERTY. <br /> F1tIB copy <br /> OWARTMEMT DBE oRLT <br /> AwF..Rs.AssrM <br /> BY v Ow. I Nr <br /> awe•.�.I-.Br 1� (ti.-� O.I. CD Pf.RP Mstllew IT D•�• <br /> C., <br /> ACCOVMTM.oml_ apf EAC, <br /> FE <br /> CODES iETi1MO ANOINT PFTIITTETI CIRCRIFARN i R[CTIVEO BT OATF PBMTI16IMCE REQUEST RVASfi{ INv04'E <br /> Sb _oo lvolb�� S l5 K,3k DD FSL <br /> PMD.HRRIth Sw..-EfN1N.173(31W <br />