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APPLICATION FOR WELLIPUMP PERMIT <br /> _ SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION \r/ <br /> P OX 388,304 EAST WEBER AVENUE.STOCKTON.CA 95201388 <br /> (2091489-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CRlnplala In TFiplks[F) <br /> Ar"ICATMN OR IIERE RY MADE TO TIIE RAN JOAQUIN COVNIY Fon A PEnMl/TO CONSTRUCT AND/On INSfAiI TIIE WorK DEPCnlRED.TIOR APE'I.ICATION IS MADE IN COMPLIANCE W"It SAN <br /> JOAQUIN COUNTY DEVELOnMF.Nr TOT Lt.C//IMRE,R.B0-111115..3 ANn 11 IF.STANDARDS OF SAN JOAOUIN COIINr�Y)r UUStIC HEALTII vmncER,F.NNRONMENrAI HEALTH DIVISION.,}y <br /> JOS ADDREAS/OR AI'/N/ /^/ /1 J`. /,JtAG PARCEL M2F/AtVJF <br /> OW1IEWR NAMF_1-/[1.��/��/�/1,.�/(-,.us��GF� ADORFRR(7LY/(/(�'II,1�� ir...• /�� _ hroNE1 <br /> CONI RAC TOR [�Z/Z�y-LI L7Ce E///t'YMY.1 ck'i�f_3��ILY�Li CSF isA-5 6-- <br /> [�_AnnnFaa �J l/�fOjjJZ nlrnnF�-"112 ,,q[�) <br /> RIIR coNTnAeron.X%LEi E^iY�.IGA?TL¢IJ 1/iC S� /N�� ADDRF.sR/ J�yiQl/F�tn(1� LIC 5[ 4 16 n1ow <br /> 4yjmf=l cad" <br /> TYPEOFWtgLwMF. NFWWELL ❑RFMACFMFNT WEIL tT-1PMoNn OPoND WELL e! :3 ❑OTIIEn <br /> 13 IIIal ALLATION ❑WELL SYRIEM RFPAtn 0 CnORRLONNECT REPAIR ❑VAMn FRTMIO <br /> CTN WELL <br /> (11 YET or I`/Mr) <br /> ❑m—13n—t, Mr. DEPUI PUMP SET_Fr. FIRST WATER LEVEL O <br /> ❑ <br /> OUT-Or-FF.nVICF WEIL ❑REOMOYPICAt.WELL t o..."f� R <br /> ❑OF01 mucTtow <br /> NtENDED USE TYPE <br /> OF WE CONI UCIION NECIRCATIONG A A <br /> ❑INDUSTRIAL F❑f-lIopmpOTTOM MA.OF WF(L EXCAVATION ''ll DIA.Or CONOUC t On CASINO Al/? O <br /> ❑DOMFRIK:RDIVATE LJ DRAWL PAr.KIRNF TVI'F Or CARING/Rtffl/PVf: vL•'A n1A.Or N71L CASINO I�R O <br /> ❑mmur AU1IMCIPAI ❑DRIV[N flfl•III Or GROW RF.AI. RPFCNICATION �T " <br /> r❑�NKOOAIK)NMO ❑07 lit" Onow REAL MST At1 FD FY � ONLY RMND NAME X4174 E <br /> yG MOMTOnINO onout sm.PNMPFO:Elv- 9-m. CONCnntpf..nFSTALRYOn11tF,n:OY« S <br /> APMON."Trill IACKI O CNFaffn ROKMTOVE nPE L-1- 1 <br /> MOPORED CONSTRUCTION/DRILUNO METHOD:MIND MTA11Y AIR"OVAnV AVOER_'­� CARLE 0111E11 <br /> 1IIERFgY CFn(IFY TIME 1IIAVE PnEPA"To T/LIR APMMATION AND MAT INF WORK WRI,PF DONE IN ACCOMIANCF WITII RAN JOAQUIN COUNTY OMINAIN-F.S.MATE LAW",AN"RULER AND <br /> MOI"ATMNR Or TIIE RAN JOAOUtN COUNTY.IIOMF ONMFn On IWFNFED Anrm,s POO ATURE CERTIFIER THE fOLtOWING:'1 CFMWV THAT IN TIIE mroRMANCF Or me WORK ron WIItC11 <br /> AIRF PERMIT Is IRRUFO,1 RIIAIL NOT FMrtOY PERSONS RUl,JrCT TO W"nKMAN'[CONIPFNR4110"LAWS OF CALIFORNIA.-COM MCTOn'R ISIONO On RUR-CONT nACTI"n SIONATUnE CEM IfIEs <br /> T/IF roll OVANO: -1 CFMIrY THAT IN 111E PERF0 MANCE OF 71R WOII(FOR 1Mi1C11 T1RA 1'F11REff Ip iSRVFD,1 p11All EMPLOY PERA"NI II1pJFCT 10 WORKMAN'[COMnENRAUON IAWI M <br /> C AI IrO <br /> .'._PK"MA..fiK AFMANf f C a IN AnVANCF.TOR ALL RF01S"ro nvRPFCNONs AT IMII 4.[.:N)1.COMB—Er EE RRAM�tN�O AT IAWEn AMA 110111o.D110111o. a <br /> �C ✓ nR.l/���1L Cl� D���Z"/sem'—..� D.1._/�7`` <br /> Plnr A.IT.—1.MJ.t a..,a 'ro <br /> 1. NAMFA OF MnEETR On ROAD$NFARF,RT TO On POUNDMTMPE <br /> n 111E r "TY. A.LOCATION OP IIOIIRF,srWAnt nIpPOSAL IYMFM On ronr-o SM <br /> 7. OIIit"JE OF Tiff rrKIPERTY,nIVRM nIMFNR1ONs AIT IMnTII DInFrIMN. FKPANRION Of RrWAOF MAMAAL RYMFMS. <br /> :i.n:1AFNAlow.omttHta ANO LOCATMN Or Alt FIOgTINn AN"MOMFFn S.LOCATION Or WFlts W"/LIN"AMUA OF ONE IIUNDIIEn VWIV r(. <br /> At nUCTUnER,INCLUDING COVERED AREAR RUGA AS PATIOS,OtEVEWAYS,ANO WALKS. ON TIIE MoPEMY On AnionaNG rTbPEnrY. <br /> i <br /> DEFMTMENT WE ONLY 9 <br /> A,,81-1 O AnnnnlM RYV /e / b.1• �� L Aru <br /> O:nU MOnPeRm AY D.1. Pmn In.n..rt.n ITY— <br /> D-1111.11— <br /> f /ylS sub�Cc iy WorK rvlod�--t U!l 12(J"751 �o <br /> - s _ InE, amatw10 ,l -r well oer s <br /> ACCO VNIINO ONt Y: AM, FAC, <br /> rt COOEa FF.F.IItro AMOUNT REMITTED CIIECKFFCAAII,(nferiven RY DATE P'"WRT/SFRIVICE"EOVEsr NUMRM INVOICE <br /> I -- i $ I Z3 b11 <br /> Pleb.Health Sew.-Enviro.173(3738) <br />