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APPIICATION FOR WEMPUMP PERMIT <br /> 120 SAN JOAOUIN COIINIY PUBLIC HEALTH SERVICEP <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P�eOX 388,304 EAST WEBER AVENUE,STOCKTON.CA 95201388 <br /> (1119) 4119 3490 <br /> y/ 1 YEAR MM DATE IISM <br /> ICampVrF M Trip"EvIAI <br /> MMIC ATION A1IIF11F NY MADE TO TNF SAN JOAnU1N COUNTY FOR A PERMIT In Cnm TRMT Minton INRIMI TNF WORK DFRCRIRED.TI09 APPLICATION to MADE NI COMA IANCF WIM RAN <br /> JOAGIAN COUNTY DEVFI.o"ArNf Tl� I <br /> I F.CtIAP7ER 9. 9,3 AND T� I11N nAnn"or gAF InAnCnmry PU1p IC HEALTH--19.FNNRO—INIAL NFAIIH"Vi—N. <br /> in"ADORE SOMA AEN/ VE y x J `r'?jnC <br /> _CITY PARCEL SIFE/APN/��__ <br /> OWMR'S NAME AMMANC <br /> CONTRACTOR_ .•� - f AOOMARl_J ��t•'A��L^, LIC/✓P 'r'._�11gNF/�%Jo�O` ' <br /> MIA COMRACiOR �-_•�L <br /> AIIINITSR <br /> PIONF 8- <br /> TYPE OF WELL/PUMP, ❑NFW WELL ❑SFAACFWM Writ ❑IoM,n.,Nn WEt1./ El OTHER <br /> ❑INgl Alt A7gN ❑WELL BVRTFM REPAxI ❑C.RO. MHIRCT REPAIR ❑VAPOR EXTRACTION WELL/ <br /> ❑N.uv❑ '! <br /> RYA OE PUMA P-0, H.P. - DEPTH PIMP AFT----FT. iD18T WATER IFVEL <br /> ❑OUT O�RfSVICi WIIL •lei'-.� PIv RICAI Writ I 0 <br /> ❑ SOK BORING A <br /> INTENDED USE Y OF W CONtIRVC 11oN sPECIf ICAT10N <br /> ❑INIRISTRIAL ❑OPEN MITOM -_--_ A <br /> GIA.Or WTI,fxr.AVAIgN INA.OF CONDUCTOR CASINO <br /> ❑nOMESTICSYRVATF ❑nRAVFL PACKMIFE D <br /> TVA of cnAluOmlFi1 RnJC DIA.OF WELL CASINO <br /> ❑AIRI.ICIMUNICIPAI ❑nMVFN D <br /> Of PtII Or nMl/l RFAI MECKI('ATION <br /> ❑MINn AT IoN/AG ❑OIIIfO ---_-- R <br /> RMIII aFAI NRf AIIrD AY GMM ARANO NAMF i�VI.Q'(,`• <br /> ❑ <br /> MONITORING GROUT RFAI PIMPED:❑Vrq (IN. F <br /> CONC'%-ff PF.DFSTAI"YrWAI.1q:❑Y- ❑rl. <br /> APIPIIOx DEPTH1 nCM SIO f/RST/R Rn YIR10 VF 1'll'E <br /> MOMOVI)CONSTRUCTIONIOISLUNG METHOD' MUD SOTARV ! <br /> AIR MTARV AI10111 CANIS <br /> OT/IFR <br /> 1 IIf NpY CERTIfV 71-1 I HAVE PRPAIRn TINS AM MATION AND THAT 1IIr WORK VA RI nnNF N AC.f.ORDANCF"TIT SAN MAGIAN COUNTY ORDINANCES,STATE TAWS,AND"'Mrs <br /> ANIt <br /> RFO VIATgNA OF 111E RAN JOAOUIN COUNTY, IIOMF nWNFn OR I WtU fn Anrrff'9 AIGNAIIRR CIT RIES THE FOLLOWING:•1 CERTIFY THAT N 111E PEArO11MANCE Of THE NRHD"'M WIIICII <br /> TIIIA PERMIT IR 199UFO,I WHAIt N07 fUrn oy ARNONS RUSJFC7 TO WORKMAN'$COMPFNSATION TAWS OF CALIFOgrNA.'CONTRACTOR'S HIRING OA OUR CONTIIACTNO SNINATUTIF CErtf RIES <br /> LIR FOtIOVANO: I CERTIFY TNA7 TNF PERfOPMAUCs OF THE WORN FOR WHICH T1R"PEltlNIT IS MSl1ED.1 SHA11 FMA.GY PEAgONR SUSJFCT TD WORORAN't COMIrf11/AOON 1 AWS of <br /> CAttrORrA T11 IC AlT C.11 71 Immo W"I",vmF-a#1,r1r 1.14.10 lm S.' SIIONA AT 17001/q 11ft.COMA ETF GNAWING AT IOWFR ARRA <br /> ,4�f-\) 1'110 VIOFO. 3 <br /> Slp.yd x A�.Yf��l TNI. <br /> PLOT PIAN In—11.RnN.1 f4d. •Iw <br /> 1. NA Ats Or RTRFFTS OR MADS NEAIRRT 70 On pO11NI11N11 INf FMPnIy, <br /> 7. nU11iNE OF 111E IYOARTY,01NNn DIMENSION"AHO NOR/ll MRICTION !. LOCATION OF IIOU"F SFWAOF nIRPOaAL sy"rm OR Mr..rn <br /> :1. IxMrNgrnNEn OUTUNF"AND LOCATION OF ALL FXIRTINn AND rvtn-RFn FIICANSION OF SIWAOF DINPRRAt RVRT1M/, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WAI KR /7V 6 LOCATION OF WFIL@ WRIIIN Mn1U8 OF ONF MINOnfn IIfTY ET <br /> ON THE PROPERry OR ADJOINING PROPERTY, <br /> "MUNFINIT <br /> f�F; vFo <br /> 41999 <br /> hwvlqS.I. G�/lhi <br /> OjN fNIl HFEAl7{ O'VISION <br /> Qll <br /> Mnnn..x,n Aee.OIR/Rr_ � O •c- �r ns �r u"F nNLr /I <br /> GrRrS Imn.rrNwn Ay O.IR-_ hnPn I.nr+eO..n Ry /J <br /> Dr.errenen Irr.Sxllrrn Ar ----- <br /> 0.1. <br /> 4.; 7y'�f <br /> Gt BGi/ <br /> ACCOUNTING ONLY: AIDS _-_— <br /> IAC.! <br /> Pf CODES FEE IMO AMOUNT ARM TTFD CHIC ICAR11 RFCRVFO NY DATE <br /> �P1R,HITT/S/ERVICEL'A�EO�U'U�i N�UNSER INVOICE ___ <br />