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pow l`l ' � <br /> APpUCATION FOR WELI..IPUMP PERMIT f3i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES )NocawktA <br /> ENVIRONMENTAL HEALTH DIVISION Ac v! <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 9520 <br /> (209) 468-3420 py <br /> ROA AEFUNDARE PERMIT EXPIRES I TEAR FROM GATE ISSUED O <br /> {} ICGIrIpMh FI Triglie9tei <br /> F.'I, 19 MPA.T MACE TO THE SAH JOAOUW COVMfY PQR A PEPMrt TO CONSTRUCT AHOiON ISOiTAU,T}IE W'Offt OEDGi0EE0 T1113 AE`FIKATIOM IY IuIAOE W C01.tRlAJSCE W"14 t# <br /> sOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 0-111 5 3 AND THE STANDARDS OF 9AN JOACUIN COUNTY PIRSLRC HEALTH SEnVlCE9 ElMnONMENTAL HEALTW OMSION <br /> FAACfL 91tTJA"', - <br /> OS ,OORE93fOR APNO r�j��t-'n• (�� �A y �y�/ <br /> SIVG //"QS �O►�'/ WV/� t _ _ •, i+• iagF,E <br /> OOJE59 _ =.• ti <br /> k <br /> CONTRACTOR - <br /> L :..t s +4 ADDRESS i-E S ...-!'L. UCI <br /> �� ..rniwfT� ^.� <br /> PHONE J <br />�aU9 CONTRACTOR '�.....A•++-'�� 1rr AppPEsf �v F <br /> uawlo "a.wELL J •'�x 13RTNEn, <br /> rTVE OF wEulFlJraP ❑ Ntw wELL C3nEn.AefKENT wElL PE <br /> I''� <br /> ❑ RifTALLATtoN ❑WELL TYSTEIA PAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EX C MI'l WELL 0 1 <br /> ❑Nwr❑r4+M H P OEPTW FAP SET FT mmrr WATM 11-IMLl�„�� O <br /> i1wf OF"J-PI ❑ Wm f <br /> i <br />�C DE9TRUCTTON <br /> d <br /> IM1EN0£O Ufa fYFf Ott COMSTAiIL:TTOW SPfCIFICA:10M5 <br /> ❑OFEW sarrom OIA.OF WELL EXCAVATION S dA.OF CONDUCTOR CASMIO `L J --r- <br /> 0 IND <br /> OV9TIGAL - O <br /> DMV FL FAUH <br /> OLE I"1...-�Y = P V- JC,, ��- OIA OF WELL CAUNO <br />�Cl pgM£9TICfPR1'/ATE rvv f OF CAWWMT M0 T� p V l_ `S"ri `4 z A <br /> 0 vy�CMUW-WAI ❑DreVEN OEF'TH OF GROW SEAL, 2�J0 ` <br /> 0 R1AIpATION/A0 ❑OTHER OFiOVrSELLOWALLEDSY !'-z �. r dRlDlfrDRANONA/AE 1�C'Ll� jt E <br /> Q MONITORING aADvr am PUMPED' Ely. ON. CONCRETE PUMWTAL SY vwLttle❑Y.. 0 N. s <br /> wird. LOCKWO cHlelaER saxwow p"-f— s <br /> &r~x.OEYT14 `70•� ,� GSE OTHER <br /> .wOrosED co/rsTRtRaTroNIDraLnRa <br /> Nlrrxvo- /aLo RDTra+r AIR AOrARY AtlaEit <br /> yE� CERTfFY THAT <br /> --AWE Pr1EPl►REfl 7HI8 AJ4RJCATV"AND <br /> rNAT THE WOFK WILL Be DONE W AC'COR^""WTrH GAN JOAOUIN COUNTY OVOOMAMCES.CrATE LAWS AND MUG AND <br /> -£6ULAT1ONf Of THE 9AN JOAOINW COVIMy DW OWNER OA L="W AOENT•f gaNATVPE CERTrt1Ef TTIE fOLLOlNw1a'T CERTIFY THAT 111 THE PEArOAAAJICE t1F SRaNATUPE CERT1FIEf <br /> a FEPofr[fT Ia 1fARED i GHALL NOT ETSJ9.0Y FEAVOl1a VU%jE=To Vi1ORCp4Alr5 COMPt"ATION LAWS OF CALIFORNIA. COMPACTOR•s"MUM aR IRI"DWRACTMG <br /> FOLLOWING 'I CERTIFY TWAT n1 THE FE MI4.1•ANCE OF T*Q WOFX FOR WHICH TIDO PUMAT 1a 14CLED I WALL OKM-OY PEREONa etr3rECT A^T WVOM AMA�4 Vr1�CIAimM LArYO Of <br /> CAIIFOKMA' TSq APP11CAWT MIUQT GALJ.Rio Hot=In ARPJAMO FOA ALL RROW-=aC6P9CTIOMO AT C2'val 4C7 Xl COMMM ORA11K7dG <br /> s+w+.a x <br /> PLOT Puw 19....w 94d.1 Sam. � <br /> • � tGeAlToae aP uvtRCE tlNnGE aaPuaAl avarEXl OR FRDFvaaD <br /> MO- <br /> 2 OVTt"vF THE ©OR ROADO FFIOP'ERTY ar4*M�MAD NORM D"CTTOM EXPAiA10N OR G'.TWAOE OtGN VA aYBTE'DI <br /> OVTLRIRFf AND LOCATION OF ALL ExISTINO AND FRO OED R. 1;pCAATON OF VIIY Of WTT1O1 AAIRtR9 OP 011E IhACOxED FfFTY R <br /> 3 01FA D All PATKM GFr4WAYIL AMC WALRf_ t11M T1GE F110PErrTY OA AQASMrlO PROPElrTY <br /> STpItRC1'VPIES.FICLVOTHG COVED/11rtJSs BtA71 <br /> 1 . <br /> I <br /> I <br /> Op/Y1TMOfT UGa aMlr •- f�Q/ /`� <br /> A.o4.w.n A......d 9Y v.e. z <br /> a..w kw«H.n 8. 9'r' 0.R. <br /> "�wrwsw. L9 <br /> ACC01,IMr1MO ONLY Ax)F PACO <br /> F'E COOEA FIM INFO ASSaUMT RU-TTED R= ASW I 11(CEnrw SY DATE F'OMSITIS@MC[AXOUIXT MWISER INVOICE <br /> S � <br /> I <br /> I <br />