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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 988,304 EAST WEBER AVENUE,STOCKTON,CA 85201 X88 <br /> 12091 4687420 <br /> ROS-REFURgARLE PERMIT EXPIRES I YEAR FROM GATE ISSUED <br /> IC—Plaw <br /> I k <br /> AF'IXICAT10N 10 HERE 6y MADE/0 THE RAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTANO/ORINSI M t THE WOIK Df SCRISFD.TI 4S APPLICATION IR MADE W COMPLIANCE WITII SAN <br /> JOAOUKJ COUNTY DEVELOMAEENTT TTTT1,CHAP"7�ER 8-1115.3 AFT) TIIE BTANOARDO OF BAN JOAOVIN COUNTY RIUL IC IIEALTII SERVICED,ENVMONMEMAL HEALTH DIVISIOW, <br /> JOB ADOREne,OR APNO O 4✓) �1 {'��f'-re to 2 c� --7-k o r r�v\J <br /> /��L �/ /� C'TJ lC� �I PARCEL D12E/AR// <br /> OMNI FT'S NAR F- l"^^-J� / 1 A/l M A.� ! •AODRff{`�!/� (J �../^Pe I-Y✓� PHONE F -/ `•'�7 '7 <br /> CONTRACTOR L- N I -�\ LL/l�� AODREBS tU-r t l h I�I I r UCI 3J1stld RiONE R 't6 / <br /> BVD CONTRACTOR <br /> —'� ADDRESS LIC• MON[R <br /> TYPE OF wtI.u"IMP ❑ NSW WELL ❑REPLACEMENT WFIL 1❑-�MOMTONNO WELL I ❑OT.FM •v <br /> ❑INR;ALLATION ❑WFtI SYSTEM REPAIR ❑CROSS CONNECT IIEPAI ❑ VAPOR EXTRACTION WELL <br /> ❑N«,•Q 5-11 H.P. DEPTH PUMP RR_ J <br /> HYPE OF NMP) FIRST WATTS LE`RL 0 <br /> U OUT OF AIRVICE WELL ❑ OEUMIYBICAL WE, / ❑ BOK.ItOnl11G <br /> �.JI R <br /> LOf STRVC710H• V J - y C2 L G S�AC/C <br /> NIENOEO <br /> US VIE OF CONOTRVCTION{P ECFICA N{ <br /> ❑INDUSTRIAL ❑OrEN BOTTOKIy' <br /> DIA,OF WELL CkCAVATIDIA,OF CON TOR CASINO D <br /> ElDOMEStIC R`WVAI[ ❑ORAV PACK/BZE IYPE OF CASINOlSi FFt C___ • <br /> —. _ OIA OF L CASINO Q <br /> ❑('1181 K%/MUNICIPhI ❑OISVfN DEMII OF DROUT BE <br /> VECIF T10N <br /> ❑FRSIOATON/AO ia SHIER r L,T OROVT SFAL INET .LET)BY K <br /> ORO BRAND NAME <br /> EJPFROXX OF, F <br /> A13 GROUT SFAL PIE FFG:❑Yr (]N. C RETE PEDESTAL SY ONLLEIL❑Y ❑N. 5 <br /> .DF..T« � Q a <br /> L KINO CINBTIR BOX/ PE S <br /> T'ROTb{ED CONSTMlC 110NlTN{IUNO METIOD: UD ROTARY _APR RO Any AUGER `— BLE <br /> OTHER <br /> 1 HEREBY CERTIFY TEIAT I IfAVE TFTEPARFO TIIIO APK ATION AHG THAT THE RK WILL BE WE IN ACCORDANCE WITH AN JOAOVIN COU OMINANf ES.STATE IAWS,AND RULES AND <br /> f1EOLRATIONB OF TIIE BAN JOAO"N COUNTY. NOME ER OR L"NSED A NT'S SIONAT PPE CERT IFNs FOLLO`. 1 CERTIFY THAT THE PER/011LA ANCE OF T11E W W FOK"W" <br /> TING PERMIT N ISSUED,1 BIIAII NOT TMROY IFRBONS JFCT TO M'OpItM 'S COMPENSA LAWS OF C IFOIS•' OM RACTOR'0 M O OR SVD CONTRACTING SIONAIURE CERTFTES <br /> 1HE FOLGOWNM: i CERTIFY T IN T11E I`fRFOTW AHCE F THE WORK F R W1/K:11 INI{P[F1MIT IB ISSUES, 9H/ l OY 1•Ep SONS RU ECT TO WOpgAAN'{COMPENSATION LAWS OF <br /> CMIFORNIA.' ALJ MVO Sty 2 f IN AD NCE 10". BEOII -IN{(TrfOH�O AT 4 1. C/O.M.ET ORA Al"OWE"AREA J VICE D. <br /> Byn•d X �(f, /� D <br /> FLPLAN AM —e. e M <br /> Bn Y.I S • Is <br /> 1. NAMES OF ST/if FTS OR MAO$NEARTST TO OR DDIINERNO TI I STY, ♦, O ON OF must [DISPOSAL DYSIEM OR PI'OMO[O <br /> 2. OUTLINE OF THE F.OPFIITY,OIVWO DIMENSIONS AND NORTH IRECTI EX NRION OF OEWA DISMOAt SYSTEMS. <br /> 1. DIMENSIONED OVtUNFO AND LOCATION Of ALL FXIRTINO A I` 1'$ {. LOCATION OF WE WDMN RADIUS OF ONE HUNDRED FIFTY F7. <br /> STRUCTVRFB,INCLUDING COVERED AREAS SUCH AS PATO DRIVEWAYS, WA-XV, ON THE HIOPF OR ADJOINING PfOME. <br /> ..... - Fn-T. .... <br /> • 1997..1... <br /> aPrQll1 _ µµ Ys fST/I�/q <br /> s_ <br /> C FTi . <br /> b"ARTMENT VSE ONLY <br /> APPib•Ihn Aa..pten By OPP• My 2 t -- <br /> ae,A <br /> DPwPi��thn In1I«Pbn DY1 /QBE/ _ ONPI.--�/—/� <br /> 1 ACCOUNFINO OILY: �AIDI FAf,I r <br /> F{C00ES TFF INFO ANOINT REMTTFD CHECK ASII TECOVEO ST OATF P[1VAI IISFAYIC[REQUEST MIR.IBBI IHV01C[ <br /> to0k_5aY �} 3/ - 7 <br /> S� O6 rzv34 <br /> Pub.HoGllh Serv.•Enviro 173(3/96) <br />