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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST VIEEIER AVENUE,STOCKTON,CA 95201588 <br /> 12091 4653420 <br /> MOM-REFUNDABLE PERMIT ERPIRfS 1 YEAR FROM DATE ISSUER <br /> (CM pkl.IN TFIpk t.) <br /> ANLCATNIN M WNW BY MASE TO THE SAN bAWM COUNTY FOR A FEMAIF TO CONSTRUCT ANOIOR INSTALL THE WORK MMMM.TMs AMM M:ATpN 16 MAW IN COMMANCE IMEN MN <br /> MAd COUNTYIIEVfLOFMfM TITh,CHASTEN s.11116.3 AND THE BTAnM)A OF SAN MAW.COUNTY RRL.MALTN BFIIWCE6.ENNIgNMFMAL HEALTH WNW, <br /> Me AodIEeR,On AFNF 4.5157 L-OLIM1t-'YV C�Lf�1 1`�J CTEV '�'DN vruleEa mzuAVNr� -(/O0S . <br /> 1 ,I I co n p <br /> OWNNFS NAME 5heV10. PI'GaLL LFc4 �✓ . AdNE.. I ,0yO.-If�/U CI 3� ."Ne 7510-675616Li <br /> CONTRACTOR CA✓COe fl✓Lu Std F T[14t � Tit. AdlRfst 45D F{6 WQ 4u we 4Yn Ii ..570.313-tyOP <br /> eue cONTllAcro� AodIEss Mar vE,t3' ' <br /> ��..,,(( we FwHE F <br /> TYFE Of N'FWPIIMP. ❑HLW WE[.L O REgACfbEM VNu. O MON.ON.WEIt S� O OTHMI <br /> U INAALIAIVN O WELL SY.TEM WAM 0....C45NNECT AFFAIR ❑VAPOR E%TRACTMNI NfLLI J <br /> 11 HDROR:WS N.F. Del.FUNDS, 1. Fd.T WATER IIVEL O <br /> ff FOFFOMR <br /> O oUTOF6ERWCL VrttL O OEOR M,Fm WDLL I ❑ 6pR sOMMO I <br /> ❑dR.CTMN: <br /> INiLMOfO flOL2LWAO t A TIO..IFCIfICAi O �/II A <br /> 01MOUSiNAt X13 WEN.TTOM 17 J MA.Of WELL EXCAVATION Lf dA.OF CONFUSION CA6 O <br /> ❑.MFATICIPEI E{IOMVELPACMAOF-q��-�(AD�1� TYPF OF CA.I.ATFEIA^� dA,OF WRL CASINO — O <br /> ❑FVSLICA[UNICNAL ownew M".,-` OFRfN OF O.UT BEAT /V F LL nDECIFlCATIDN T✓6 -1 V 0 A/� <br /> ❑dwoA'.... DOTNm �a»� O.OT REAL MATAUT.SY L- o.OTeRA1ro NAME L•T]1.. -AIPr, .CI'• <br /> ASen N..... /� 4Q O.UE.EALRMPEO:OY. M CONCEEEOfRA R dtlEwOY� UN <br /> AIMOX.OpFN ZS '1"5r,+. tOCM1.CHE.TE11.Al"OVE Few <br /> II <br /> IAO.6.CONFNIUCTIONAMLtNNO M...' MUO.TARY AM.TAM A.ERY _CMIE OTHER <br /> 1 HERBY CERTNY THAT 1 HAVE FREPAREO TIII.AR ATMM A.THAT THE VANE WILL Rf OWN M ACCO.AMW PATH SAM MAMNM COUNTV O.WANCER.STATE IAWY,A..Us.9 <br /> AMMIATIONR OF THE.AN MAWd COUNTY.HOME OWMEN OR MENDED AWNT.NONATVN:CERTIFIES THE FOLLO"AN 'I CENRFV THAT M TND FEIiOMA.E OF THE MAIL MR WHICH <br /> f T141 11.1p IRISMNO.I WALL NOT WORDY PERSONS SUSJfCT TO WORKMAN'.COMFDNSATNIN UVA OF CALIFORNIA.' COMMCTOWRWNW OR.siOMMCTM IMMATURE CIUTWMf <br /> LNE.LLOFAM: '1 DEdRY THAT W THE RMFOMA.E OF THE WbRf FOR WNMH EHN KRAIT IR ISSUED.1 SHALL EMKOV DIVISIONS IRMUECT TO WORNEWW'S COMMMATNIN LAWS OF <br /> ,A.FOMWA.-,MlE A IRWANT NWB CALL N MOW W AOVAM W FOR ALL RDOLNILO IMSPIMM AT MOST/Atl-iR.R.COM IL"t OMWMO AT MINES AREA PROVIDED. <br /> I�a...X ✓ THI../A/PLT" U-Go�041J7 ..I. <br /> V77 rtOT RAN WR <br /> 1. OVILWE FS THE MROR.,NVFWFRS KDMIMMUST M OR.UNM.TMKOKRTY. 1. LOCATMNOiMUM IONFOM..SAL UJDM. FM OR ROPoR[O <br /> [.OUTLWEERTIIFTUNDS A.ND UOCAION OfIAtt AND.RADO FROMN. fMMHSMM OF FL*VMINM SOF MN. <br /> J. dMCTURES OVTIMK COVERS AREAS SUCH <br /> E ISTEIRI srATKA.RMPo6[O S. LN THEI'NOi WYO IWfHMMMUSOFONE NV.PEO fNTV FT. <br /> 6iNKTURB,MCIVM.COVERED AREAS 6UCH AB PA1Ms.ONVfWAVB,AND WAIRB, ON THE RMKRTY OR AOJOININ.AOKIfLY. <br /> 54e ca.(4aake-d P-jure 7— <br /> `1 5��� L,(� c�wcl P,-oPosed �044L{9vin' Wlu Loca�,o 1'.11 <br /> n <br /> OEPARTMEMT U.E ONLY // <br /> n.Rn.NM.A—tl Sr OM. 112 ' {QW w.. 315n,T // <br /> mmn L.Psnen er OM. n.RP ImFeIMn h DFIF <br /> ACCOUNTINO <br /> n..MR.n..linFm:iwi er O.I. <br /> i <br /> OMv: Mw FACE <br /> PL Com FEE INFO MAOVNT RLMTE. cHEckINIMN NLC.M.Y OATD FIEMrALIMCe RDMR1T NIM.ER INVONL <br /> 5� 522 lZ•L IZ9-0 <br />