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I <br /> APPLICATION FOR INELLJPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,4415 N.SAN JOAOUIN ST,STOCKTON,CA 96201381 <br /> (201)4433420 <br /> RRMBEFUNDABLE PERNR EVIM I YEAR FR911 DAT ISE SUED <br /> (GIgYb IN Trio a <br /> A/PUL.ATKIN It HERE rN MADE TO THE SM JOAQUIN COIMTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK OESCOUffD.TWA APPLICATION It MADE N COMRIANCE WITH SAN <br /> JOAOU*COUNTY DEVELOPI"T TITLE,CHAPTER a1115.3 AND THE STNV OF LAN JOAQUIN COUNTY PIf IB C HEALTH SERVCEI,1!4 I NBENTAL HEALTH W"w"N. <br /> JOS ADOPEMXR ARI Cm FARM DGMA N <br /> ONSRXt NARY At, ADORERS PHONE 0 <br /> CONTRACTOR L ue/ L-RIDFE <br /> tut CONTRACTOR AOORFSO UGI PHONE• <br /> TYPE oP wtu'TLEMG IR AP NEW— ❑Po-LACHAENT WELL ❑wwroM10 wEu/ ❑GTHEn <br /> ❑../itwo 1AT10N ❑Wcu wurEM REPAIR ❑CrotbCONWCT REPAIR ❑VAPOR EXTRACTNW WELL E J <br /> TYPE/4(� NfElwv❑E1q,1, H..� OErrH Mr tET__FT. FIRST WATER Ll'V F 0 <br /> TYPE OF RIMPI �'P� <br /> ❑OUT-OF-SERVCE WELL ❑GEOPHYSICAL WELL I ❑ SOR soHIK: a <br /> ❑DESTRUCTION: <br /> CQN#3Njsn3m SPECIFIC wTOM1 // / A .Il <br /> ❑I AL OPEN tOTTONI MA.OF WELL EXCAVATI4GO DIA.OF CONDUCTOR CASINO 0 <br /> 111L <br /> SVATE ❑GRAVEL PADVRIE TYPE Of CASINGKTEELIPVC DLA,OF WELL CASSIS Sr O <br /> ❑RISUGMUNCPAL ❑bPVENI OEPTN OF G110UT SEAL WOwICATION R <br /> ❑NIIOATION(M ❑OTHER GROUT SEAL INSTALLED rN0"14 GPOVT STAND NAMEf <br /> ❑MONI omiwa /� GROUTU.F <br /> SEAL PED:❑Yw D CONCRETE PFDESfAL Sv Wl1PR w C3. S <br /> .11.SEPTI 3„R,EEJ _ LDCNNIO CIE STEN tOXlSFDV!PPE ^_ // _ 'J <br /> 111DPOEM CORST1UCTIORMPOUJIM 106THOD:mb A0TARY NR ROTARY AUCIU _CAM-I ✓ OTHER , <br /> I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK Wal HE DONE W ACCORDANCE MATY MN JOAQUIN COUNTY OPI N-110ER RATE LAWS,AND NADI ANO V ' <br /> REODUTIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER O\LICENSED AGENT'S MHATURE CERTIFIES THE FOLLOVAIO:'I CE/RFV THAT IN THE PIRFOPMANCE OF THE WORK FOR WHICH <br /> THIN PEM4T It MWED.I*HALL NOT EMPLOY PERSONS WSJECT TO WORWAN't COMPEMIITNPN LAWS OF CAUFORMA.'CONTRACTOR"S HIRING OR SU&CONTMCTWO iONATUIE CERTAEt <br /> THE POLI 'I CERTIFY THAT IN TIE fSA,YNCE OF THE WOPR POR WHICH THIS PEMIIT 4ISSUED.I SHALL EMPLOY PERSONS WSJECT TO WOLIgMAN'S COMPOItATON/AWE OF <br /> CAU►ORSA.' TIE CANT MU T C NDVI IN AIYV RICE 1"OUR ALL MOMPRO INSP ONt AT ItSSI AM JMR2.COMP TF ORAW WG AT LONER AREA RIONDED. <br /> NSr./K ` _TM.� <br /> 61 PLOT RIAS .v trip teW __ <br /> 1.NAMES OF WMETO OR ROADS NEAREST TO OR SOUNDING THE KfTI"1'. �. -CATION OF HOUSE SEWME ONPOSAI.SYSTEM OR PROPOSED <br /> R.OUTLINE OF THE PROPERTY,OIVINO OtE1PS10Nt IND NORTH JON. EJIPAMSIOII Of SEWAGE OIiOtAL.SYSTEMS <br /> S.OEENNOFED OUTLINES AND LOCATION OF ALL EXISTING AND PRIOPOSEO S.LOCATION OF YMIS WITHIN RADIUS OF ONE HUNOMED FIFTY FT. <br /> tTIM/CTLAER INCLIIOIN G COVERED MEAS SUCH AS PATIOS,ONYEWAYN,ANS:WAOSt. ON THIS <br /> P�ROOPE�RTY�OR ADJOININS PROPERTY. <br /> 07 <br /> j pAYMEN ..... ... :.. . . :._...... <br /> i ... <br /> -RECEIVE : <br /> ;SUN: 5 1995._..... ... .... .'...... ... <br /> SAN J04Q0IN COUNTY <br /> PUBLIC HEALT14SERVI S ;.........:....; <br /> ENVIRQNMENL' <br /> OIPARTME NT INE ONLY <br /> App"~A--N /u— <br /> I'Ne.rt SSysEan ByT ' .%a—tYPP.m-BY r 9 <br /> Prnrlb..a.Is.eNtA BT_ UR. <br /> C—; <br /> ACCOVNTIN'A—Y! ACR <br /> M COO" FQ 0— APAOMEC N RT pIII IASElves SY DATE PFMSTWERACE RTiGME <br /> EST NU 61 IFIVT.TCS <br /> i h3 om r)& <br /> � <br /> , o i Io <br /> -cx 0��o <br />