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ti APPLICATION FOR VVEWPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O, BOX 388,300 EAST WEBER AVENUE:,STOCKTON,CA 9S201,388 <br /> 12091 4683420 <br /> NOR REFUAOABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> 0Ipl <br /> APIEICATKIN M HERE BY MADE TO THE SAN JOAQUIN COUlIY FOR A PERMIT TO CO NRPRl1CeTIANO/ORk NBTAEI THE WOFK DESCRIBED.TIDS APPLICATION It MADE W COMPLIANCE WR11 BAN <br /> JOAQUIN COUNTY DEVELOFWEENT TITLE,CHAPTER B 1116.3 AND THE STANOAIMJS OF SAN JOAQUIN COUNTY PURI IC PIEMI41 SERVICED.FNVW404UFWAL/1EALTN OI VISION. <br /> Joe ADOnfse'oR APNE Q O I ! Y�Q rTC{tJ TL.o r�r�LTJ <br /> ^4 F cTY PA/CFl eIZF/APNI <br /> OWMR't NAME <br /> �. AODRESV��/ '/^/PC I SIF t /•��R10N3 <br /> E/ —/ `•' <br /> CONTRACTOR �_C.A�r< rtl c._. AODRERt 20'ZS�C-- `PI <br /> PVD CONTRACTOR <br /> -- ADDPESe LR:1 _PHONE J <br /> IYPE OF_. MI.L NM ❑ NFW WELL ❑REINACf.ENT NEIL ❑MONFTONNO WELL I ❑OTHER__ <br /> ❑INe'ALLATION ❑WELL SYFIEM REPARI ❑CROSS CONNECT REPAt Cl VAPOR EXTRACTION WELL <br /> J <br /> N—❑Ilr.l, H.P. of PTH PUMP RET_F <br /> H vPF OF M1MPI 1I--�t FIRST WATER LE'EL O <br /> .-.J <br /> C3 OUT OF SERVICE W,LLt U G[—YRICAL WL E _ ❑ SOK,ROAl1Y0 B <br /> NIFNOEO ViTYPE Of WEL4, CON TRVCIION VPFCIFICA NV <br /> I <br /> !❑INhUeTR1AL 0 OVEN BOTTOM DIA.W WELL EXCAVATI DIA.OF CON TOR CASINO <br /> U DOMESTICrt VATS ❑ORAV PACKfe:TE TYPE OF CASINOISTEEL. C__ O <br /> OIA OF LCASINO O <br /> ❑PURLICIMUNICIPAL J7E❑• OPovIN MPTII Of DIIOIR Be VELI! TION <br /> ❑KV110 ATq NIAO Tu Oi HFR lr T OROVT VEAL INET LED DY ORO enAETD NAME R <br /> Cl MOMIOn1Fq I� F <br /> y Q OROV/FFM.AI LTO:❑Vr LJ N. C RF/E PEDESTAL SYDM1f R:[3y- [j.. <br /> 5 <br /> APX.pf. TH l� L KIND CHESTER SOXI IE <br /> 5 <br /> PROPOSED CONS T/1l/C TIONYOW LUNO MFT NDD; UD ROTAgI' AIR ISO <br /> MV AUGER BLE <br /> OTHER <br /> i HFR:SY CERTIFI'THAT I HAVE ItIEPA11F0 TWO APDL ATION AND THAT IHE W VYILL BE NE IN ACCO/IDANCF WIT•A AN JOAQUIN COV ORDINANCES,STATE LAWS,AND RULEt ANO <br /> RFOLRATIONB DF TILE SAN JOAO"COUNTY, HOME In OR LICENSED A fIT't 81GNAT KE CERTIFIFt 1f TOILO` 0 1 CERTIFY THAT 1 THE PFW(IMAANCE OF TILE WOR(FOR W1SCN <br /> YIKt PERMIT le If SUED,1 SHALL NOT FMIEOY PERIIONS JFCT TO WORKM •t COMPFNtAUWS OFC FOM' ONTRACTOR' <br /> THE fOILOVe M O OR tV0 CONT RACTINO SIGNATURE CERTfIFV <br /> YILm: CERTIFY RTIFY T IN TOM IEIMONAANCE E IME NYOR(! R LVI{ICII THIS PERMIT IS ISSUED, SHz OY PERSONS SV ECT TO WORKMAM'V COMPENSAnoN UWS OF <br /> CMtlORNIA.• �Il MVV t 1 V iN AO RACE FOR. RFOURFII IRSP,{CTiON/AT 1 1 f, C ET DRA AT LOW"AREA NDf O/.�//�'y{//} <br /> eTfn.a A �(J• TIII. /J1 <br /> _ p <br /> FIOIRAN w ti Bu Y.1 V.M. 10 <br /> I. NAMES OF STREFTV OR ROADS NEAREST TO OR VOIINUINO TI l O RT-Y. 4. O N OE HOWDRPO SAL SYSTEM ORBE <br /> Plnrot[p <br /> 2. OVTI INF VINO OF THE PROMRTY,b 111MENSq Nt AND WORTH InECIl E NBION OF SEWA DiBIV SAL tYSTEMt. <br /> 1. DIMENSIONED OVTLINFS AND LOCATION Of ALL FXIRTINO A "Roms S. LOCATgH OF W[I WRMN Mond Of ONE HUNhI1fD llf R <br /> STRVCTVIIEB,INCLUDING COVERED AREAS SUCH AS PATIO DRVEWAYS, WA'AV, ON THE PROPEZ OR ADJOINING PROPERTY. <br /> /i=��L FEl1-TY. <br /> U., s Nab <br /> 1991. <br /> ,,IY nl <br /> a��1 I sTIAI ti <br /> ... . ,... . . . <br /> o t� <br /> / cit. <br /> DFPAATMENT VSE ONLY <br /> Applb.iNn goo.plM BY <br /> OI.Vi YrPs.11a�Sr_ 1'amF tn.Prtlsn Sy__ U.I <br /> UwPt�tl.n In.P«lbn VY D.I. <br /> ACDOUNIINO O,lLY' nrof Inf,E -- f <br /> Pf CODES _ FFE INFO AMOUNT Pv TTFO �C/IFCXl AVID RECEIVED By DATE PFIMAi IIVERVICE REOUFST NLMBFR INVOICE <br /> 7 <br /> Flub.Health SerV.-Enwo 173(3/96) <br />