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APPLICATION FOA WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 3Ei8F 304 EAST WEBER AVENUE,STOCKTON,CA 9S2p1 W <br /> 12091468-3420 <br /> MON REFUNDABLE PERMIT EXPIRES I VERA FROM DATE ISSUED <br /> IC/InPleb In Trblkllel <br /> APPLICATION MJRFe BY MAO[TO 711E CAN JOAOUN COVNTY FOR A IEFRNT TO CONRTFIR;I ANUMA INSTALL THE WOW OEFCR9FU.7101 AR'UCAIMM IS MME 01 COMPLIMCF VWN SAN <br /> JOAOUN COUNTY DEVELOFMENT TALE,CHAIrFER 8-1116,7 AND TNF IT S Of EAN JOAMJN rOUNTI' LIC N[AtT1f 6[RVICE9.Pt VRIDI/MEMAL HP ALTH DIVIefON, <br /> JON MDRERIIOR APW rR PAOCR 1Nf1APH1 <br /> OWNER'/NAM[ AOUPE91 <br /> f1FONf 0 <br /> CONTRACTOR <br /> � AOUOFFA _IHOMF <br /> W <br /> eM CTMCTOR AD W- UC• _^AMM[/ <br /> TYPE OF WLl ❑NEN WFLL ❑RRA"W.T-[LL ❑AiONROWM'1 WFtL• ❑OTN[R <br /> I ❑W_F;L 11RIFM MPHR 11 CN99 CONNF ❑—POR F%TMC.ION WELL I d <br /> OFRYIPI ❑/ R•• HP. � DfPfI MMIFF' <br /> Ff1 <br /> FIRST WATER LFVTL 0 ION <br /> ❑OUT Or GIRVICE WELL ❑01.—IPP'AI MtL I ❑ mi.ROf11?M IF <br /> '\ <br /> 11,11m D�[O� TYT.F WFll GOft/TAUC IIOM{PECINCAi1DN/ A r\ <br /> FTLf_TTT //N10VTF.AL ❑ORM ROT70M DIA.OF YITIL EXCAVATION UPI,OF CONDUCTOR CASWn <br /> UldIOf RTICA VATT ❑DRAWL rAM. ft1E(_ TYPE(ff rARINO/RT FTl1Pt,T- dAOFWI, EICASINO 0 <br /> ❑PM ICAMt WAL ❑DO—FN OEM II OF OROUI Sf At___ ITECOFT L R r� <br /> ❑MONAIIONAAO 11 OTHER OR[HR 4EAL INITALLFU FY OROUT FNANO NAME F <br /> ❑MONPTO/1M0 OROVi IFAI PUMTEO ❑Y•• UN. CONCIE'IEP[TxRALFYRYLLER❑Yw ON. a <br /> APAtpe .—. LOCIONI)CHFRTR ROXMOVE AIF_ <br /> FTFOgtrD CORITTRlGRORIOIFLLMp MRNOD:ML/O ILOTAT'_ AN ROTAffY AMR_CARIF OIH(R <br /> I fIrR[FY CERTIFY THAT 1 NAVE FREPAIID THIS APKJ1 ATMN/NO T11AT TW WOW LVRL IE MHE N ACCORDANCE WIN FAN JOAOIRN CDINTy OIdNANC[f.RAT(UWf,ANp RIAEe AM <br /> •-•�- <br /> ROULAT10Ne Of THE RAN JOAOLIN COUNTY,NOME OWNER OR LIOr11SFD AOFNI'/RMNATURf f.FMWIFR Tiff FOUr.NMID�'1 C[IITIFY THAT N TH[/EROIFAA/ICF OF THE VbRI ipR 2 AM <br /> TM/PER.eT If Ieel11D,1 SHALL NOT FMR DY FFRbN/gQWFCT TO VV WMA"COMMOATMN LAWI OF CMROW,—CUONl_TOFLI N11fNp OR FFROUTIMNCI or <br /> HE NATLRIE CFITI 11CH I v <br /> TVR FOLLOWING: '1 CFIITIFN THA;TIN TI ROR.IAIM.(OF THE RRf11t FOR W1OCH 11419 rvr"r If 111UFD,I NIALL IMPEOY p"PID M 1UIJECT TO WOROMAM'F GOMPE711ATIOM LAWI OF A_ <br /> CALFORM ' i CA.T 11 GA HO MAFVATKf FOA A"1`116—O IR/I//�/�� mi AF TEf/11e/.M}I.COM7ETF OFA".AT LOVVFR AFEA PMDVW*n. G//� <br /> �M K 7111. ! , D•1.4�/2 / <br /> no 11D, 1.6Y0 kW 'ee <br /> 1. M FTOERF OR ROADR NEAREST 10 OR THE PAOP"N A. LOCATION OF NOUef F(WAOf DoprU l eYRIM OR ITDPO/EO <br /> E.OUTLNE Of I HE <br /> PFIOPERIY,pIVIM DRILNAONe AND NORTH RFPCTITFN, rAPA1N/IOH OF/IV/AOE d/FOFAL IYR[Me. <br /> ].OM.IINBP01aID 0111t"l NTD LOCATION OF ALL UTTFTMO AND RtORJ1F0 9.LOCATION OF W[lU WO MN RAORAe OF ONE NVIAI<O FIRM R. <br /> F TINJCTUR[e,NCIVDIMO COVETED AfEAe 9M91 M PATIOI,DNVEWAYS,AND WALK.. ON THE PROPERTY OR MJOINTNO FROPERTY. <br /> l <br /> <�.. <br /> 4T�Dz: Pa, 1� <br /> PAYMENT <br /> RECEIVED <br /> Jk 3 MAY -1 1998 <br /> 'd IS'"-"C"QUfN COUNTY <br /> ?118LIC HEALTH SERVICES <br /> FNVIfIONWNTAI HEALTH ONISION <br /> OFPMTAt T ViIT 0.11' <br /> AeW.tleO A•e•F1•A s[ `/ , <br /> -� 1�1 A.•. 2� y <br /> —1 — <br /> OsIr1sA•I,1n11•etlen Rr_ ____ O.1• <br /> Cee,n.s V— <br /> ACCOUNTIRO OMI• AIO/ fACI <br /> R CoD1e FIF INFO AMOUNT ROMITTED //ECK AAN R[[DVFO FY "ATE P6MITA191 VICE RFOIIE/T NlI1A�R1 IIMM'r <br /> O <br /> Pub.Hee RR SOIN,-Emiro.173(31'96) <br />