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P- 1 <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 3m 304 EAST WESM AVENUE.STOCKTON, CA 9 1-M <br /> (209) 460.3420 <br /> WOR-RTEUNDARTE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> tC."kt*M Trbr"W <br /> AMMATION IS,,,IE SY MADE TO TwE SAI JOAOVIN COUNTY FOR A PEAVIT TO CONSTRUCT ANONR INSTALL THE WOW MS EO.TIRE AMICATION IS MApE M COVPLIANCE NATN gAN <br /> .VAOUW COI1Ml'DEVE1pPNENT TTRL/�CHAPTER 9A1(11y1^$.3 AND THE 8}AHpAROa OF SAw JOAOVIN cou[N/�T lYj(�g/1�RyUC1}�IyfAwITN a RVICE8,ENwd/NEITAL HEALTH DIV1ISION- /•y <br /> JOB AODRES&OR APH, SnQ EI}l'S1� �V1L111c� LS 1.EM C"n�J`'VI}�L/'ITV1'1- `- PARCEL BIZE/ADN. 1�I/�O' lollil <br /> ON*RA'R NAVE C1'`CUILON AIIORCSB Q UJN% N.I./ 1"OwE( <br /> / y <br /> <oNTINGTOR 7'(TII/J �"• 1LYf G�t.NA'(�DIJ'�li yfJC" ADOREesaQ/i�Z.f�PJ(((U��^SllvjulS QA4111C117(LLIoLL�L1 LA ) I+wNE, q b \131-4(f/19U'j <br /> qJp CONTMCTOR I'Q�U�1�1J ADr1II[,661�wv �'^5"R�1 LK/ �31(l , '1 g1DNfi. 4f5/4JM:✓1�"IS <br /> pirluuoW '(�_ 4�1. 'k04 <br /> TrvE Oi WELL/PUMfT ❑ NEW WELL ❑ WELL ❑ V0w1TO.N WELL, ❑ DTIF,R <br /> ❑ MBiALUTgN ❑ M41L BYBTEH RET,-R ❑ CPORSLONNECT R m,:I ❑ VA A EXTINCTION WELL/ l <br /> ❑Nv w❑NmJ, N,V. OF".VJw SET—TT. FIRST WATFR LEVEL <br /> rTYAE of RINGI ❑ OFOVIIY;CAL M/F111 tOIRNO % 153 1 R <br /> OUTOf'IIf,RV10E VJE1,L ❑ 19 18l Wk -3 <br /> ❑DE6TRIH:TION' <br /> WifNOED U6E TTVEOF WLLL CON;THMnON;>ECIiICwTbwA A <br /> ❑ MOUgTIgAL ❑OPEN DOTTOV DIA-OF WELL EXCAVAMN O,.OF CONDUCTOR CASINO O <br /> O fbVf9TiCFMNATE ❑ORAV AACIf/L/ZE TYtT OF CA�IWIIRTEEII>VC QAM d..OF WELL CASINO O <br /> /� <br /> ❑ pUgUC/PR)MCMAL L � .&T`l y p DEPT"OF OMUT 6EAt ti' lC f -CIFCAMR A <br /> yyyyy❑TTLLLLL IRiRI:wTgw/AO 9 ❑OTNEA J OROUT S t R+6FI1-LfD SY afOIR NIFHO NAVE E <br /> IOMTORINO p��� I.f' OMM118;N,ITIYKO:❑Y- (Is. GOMCAEFf REDESTAL OYDWLLE0.:❑Y. ❑Na .S <br /> AVCRO;.OATH LOCIOW CM STEN IN)SiIROVE FIVE S <br /> ROYJ CEn COMTRUCnoAn18LUN0 A 1400: MIJO ROTARYAN MTARY AUCFR CABLE OTHER <br /> I HEaEBY CEATIFYTNAT I HAVE RKF TWO AV ATl I THAT THE N WLE RE DONE IN ACCORDANCE MRfil(ul AAOLRH COUNTY OROYNANCE9,STATE 11Wa.ANO RULES—0 <br /> /YEQULATION?OF TIE SAN"AOIRw COVIEY. NOFIE O ft OR LICENSED"E 'a BIONATUIIE CERTIHES THE RX&OWING:'1 CERTIFY 1Mwi NTIRE MRFOOVANCF Ot THE T W fOR W CN <br /> THIR pEI m pgUEp r WAIL NOT E CY PERROIB 6UH rTO Wp1 .W%COVOEN.ATIOR LAWS OF CAL40RMA: COMTRACTOA'a W <br /> IONO OR WOO OWRACTMO SIGNATURE CEfRIFIES <br /> TM FOLLOW ; -1 CERTIFY THAT W THE PEFROANANCE OR THE X' W FOR WINCH TMC V%g I;414M.1 aHAL N T IERRO"SUaIfCT TO IwORWAw•/COVpEHtATION UWS OF <br /> CAIJFORMA/'/�/]NE ApgKA�NfT�NIT CAU' HOURA IN AOVANCS ROR ALL REOWFO Iw.�IR MWS ATL iAIWP 2". ICOVTTETE ORAWMO AT LOWLR AREA IRT O. <br /> /fl . ,OraA(�ILj••�} ThN�I Fi�/� P I_G r� Dn. V/� <br /> ROT Mw Ssr.s 0.✓•1 54.1• "M <br /> 1. NAFIft or fr!"MS ON ROADS W-ASE6T TO OR BOUNCOAI THE RROrvR . A. LOCATION W t UVE SEWAGE MI RAL SYSTEM OR I MSEO <br /> 2. OVTLWE OF n IROVERIV.O DOAEw NS AMD NORTH pRECT10H, EXpANB1Ow OF 6EWAOE dewaAL QYSTESE9. <br /> ]. OwRNSY0IE0 OVTIIwF.S AIO LOCI, Op AU E< D,a AHO PKI gto t. LOCATRIN OF wETyS Y.FTHRI MONS OF ONE wUNOI1E0 F1FT V M. <br /> ,,RUCIVRES.N+[Ll10INO ,OVE"M AREAS BVCM AS PATIOS.OWVEL"/Arg.AND WAUCg. ON THE MKORAWOMINO R109FR1'1'. <br /> O®MTNMT ml OMT <br /> 3. 2moA,,—A=2— <br /> by <br /> D.I. 0 O n..,p II,.e-nl,l•eY <br /> Accouw*INa DRIr: <br /> AOF FAC, <br /> IE CODES FEE THFO AAtOLINF RElwTTEp CHECRlFA6N MGpVEO Bi GATE P9MfE/AHLMCE REOUEtTNWBER INVOKE <br /> %o a UU a <br /> PND.Hea1Dl Serv.-ETrArO.173(31W �,. <br />