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f <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468.3420 <br /> NON-IIEFUNDAILE PERWff ExvINE1 I MR FROM 01TE ISSUED <br /> PU&VkE,In 711PI-tel — <br /> APPLICATION 19"M OF MAGE TO THE SAN JOACIM COUNTY FOR A PEMaT TO CONetWJCT AND/OR NSTALL THE WORK DESCRIND TITS APPLICATION Is MADE N COMPLIANCE MTTII BAN <br /> JOADUNI COI/NTY tNYEEO TENT 7 Lt,CNAPTFR s-T AND THE BTAIJCNRIOS D BAN"AM IN COUNTY PUBLIC"VkTH SERVICES,tNVSONMENTAL HEALTH ON/1SIOHI. <br /> JOB AobnEe,An PA/CFL SLMArW, <br /> OVAIER, ADCM@e t41MA! `Hi- b CONTRACTOR SAOOREf, �t.��►1 L,c PH%- <br /> em CONTRACTOR ADbAE*S LTCI_ PHONE I <br /> TYPE Ofww . ❑NEW WEIi O FaveEMEXT WELL ❑MONITORING WELL F Q UTHER!_Sgbr <br /> �L ❑"T13- TEM WAIR ❑CMS"ONNECT REPAIR ❑VAPOR FX-(I CTpI(W-U I <br /> (TYPE OF Wyry Q N.P.N oERHPVMPBETFT. FIMT WA7FR LEVELEy O <br /> LJ ow-o"MWE WELL �{T�'I OEORTYSICAL WELL Q SoR SORNa S <br /> bESTRUCTgN: 1 / <br /> LNtDIDEp DE "OF <br /> GO 7 TRX A[ON, A <br /> ❑INVUSIMAL OPEN BOTTOM VIA.Of WELL EXCAVATION OIA.OF COHOMTORCASOR p <br /> ❑DOAAESTCATVVATE Q ORAVEE PACK/ERE__ TYPE Of CASMO/STEEUPbC LL VIA.Of WECASING O <br /> ❑PVRICMUMCRAL L3DRIVEN 0111M OF OROW SEAL "CIPTCA110N A <br /> ❑IIIROATIOWAD <br /> 11 OTHER GROW SEA¢INSTALLED SY On OUT BRAND NAME E--� <br /> ❑NOMTOPIHID GROW SEOr❑Y• ON. Come"AfOENIALBYDMLEEIc❑Y.. ❑N. s� <br /> APPROX.DOTH CMSTfR BOX/,rOVT F•PE S�� <br /> R10POSM CO**T"mmmmvMA S METNOO:MUD RatARYy_—A/R RIO ARY ALDER CAN! <br /> I NEW BY CfMFV THAT 1 IIAVE ffSMPSD TMS APPLICATION AND THAT ONE WORK WILL BE DONE N ACCOADAOCE WITH SAN JOAOU I COUNTY OPIHNA"Cit.STATE LAWS,ANO IML* <br /> REOIIIATIONe OF THE SAN JOAOUN COUNTY.HOME OWNER OR UCCN*EO ASENT7 SKINAL'UM CERTIFES TNF POLLOWINO:I COTTIFY THAT N TSE PERFORMANCE OP THE WO FOR <br /> FOR WHSCH <br /> THIS FEMAR R P„UFD,I SMALL NOT EMPLOY PfMpVNs mA.ECT TO WMKMPW I COFAfiNSATFON LAIR Of C/,t"F"A.•CONTMCTOR'S NITRIO OR SU6CONTRACT <br /> A. TNS BfO SIKwIATUI!CDRSE* <br /> IRE '1 CERTFY'iFL+LT N TK PETROFIASAVICE OF TI WOFK mA WN1CH T "FOM IS ISSUPJ•I WAIL[MPIOY PENaMI SUBJECT TO NOIBJNA/RY CO*IPOS*AiIOl/IA W,OF <br /> C k APV*T SII W N ABVANIC ALL RFLNABI® TONS AT SS)AMJ.7S.COfAF%Vt ORIAINM AT LOWER AREA <br /> e1►rf � ne. � <br /> bM• (� <br /> Kot PLAN 0—1.S.-w S.•4 '1s <br /> 1.NAANS W STREETS OR ROADS NFAKST TO OR BOL/NU*M THE l7ORERTY, A,LOCATION Of HIOUM SEWAGE DWROSAL 8Y1T[1640n Iy1UPOND <br /> Z.b"NE OF THE P"MY,OIV"G DW"NNONS AND NORTH WVC3104. EXPAN*ON OF 1EWAOE ppOSAL SYSTEMS. <br /> �.bR`*NSPOKO OVTL1Nf•ANO LOCATION OF ALL txmtvm AND MOPOSEO P.LOCATION OF WILLS WTTNB/RAD"Of ONE HUNDRED RFTY FT. <br /> SIPUCTLREe.PKLUOINO COVERED AKAR SUCH AS PATIOS.OTWEWAYS,AND WALKS. ` ON THE PROPERTY OR APJOR*O PROPERTY. v) <br /> 1 ell <br /> 1hSIj <br /> '40E <br /> V <br /> PAYMENT <br /> RECEIVr'r) <br /> L JUL 10 1998 <br /> :SAN JQAUUIN COUNT}' <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> DEPARTMENT Uff OXLT <br /> a,«A w....o•�e7� .r. P.«• -u- <br /> c•T«b.. <br /> ACCOI.MTUM ORLY: AN)/ 'ACA <br /> Fr CODES CODE, FLT IMo AMOUNT RATTED CNEc FH RLCpVEp SY VAT% FiPPa TNOMCE REOVLST Nt,A*FH1 NNVptCt <br /> Pub "oaM Sety.•Errviro.173(1197) <br />