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APPLICATION FOR WLLLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> lftlw ENVIRONMENTAL HEALTH DIVISION +� - <br /> P 0 BOX 3S8,446 N.SAN JOAQUIN ST.,STOCKTON,CA 86201.388 <br /> (2091468-3420 <br /> NON-REFUNDABLE PERMIT EMPIRES 1 YEAR FROM RATE ISSUED <br /> ICBmplet6 In TFTFIfC.tFI <br /> APPLIOATION M HERE by MAGE TO THE BAN JDAWIN COUNTY FOR A RRNIT TO CONSTRUCT ANOMR INITtAtt THE WORL DESCRIBED.TUHF}➢PLICATION IS MADE IN COMPLIANCE WITH BAN <br /> "AWN COUTETY OFVELOPMEM TITLE,CHAFTEA 9-1116,3 ANO THE 81}NOAROs OF BAN IDAO N COUNTY PUBLIC NEALTH bERVICEB,ENVIRONMENTAL HEALTH OIVISWN. <br /> JOb AOORE08AR Am.f I I CITY L O�. PARCEL BREIAPNF <br /> ATdT Cs �RA x ? ti..+, + x3 <br /> OWNER'S NAME IFIIIIFLH KCL Ph! ADORED➢ !/a Sr.. ! —HEI <br /> rr 11/ ` �MrfD itWNuA +!'.-15F.i�e `I�-I <br /> COHTRActoR tr�>J.r'TSr�vvlO..kLi�[IMU!T�Y1t i11[IA Cl flT AOOPFas�,eGuinI�CJL 9.1 S�IQ_ LICP PIroNF I�C,-YOB <br /> —CONTRACTOR Srui;l tY1Sl�CBllh��Et^IALcS�AooREbe��A ::-"_T s_A_14, 2C .-.7 FIwNE 4AJ ?l9'/Y 77�PF <br /> TYPE OFN4LLALIM_P. ❑NEW WELL ❑ROFIACFMENT w[u ❑M WORINO WELL B ❑OTHER <br /> ❑INBTALIATION ❑WELL WRIT-BF—H Q CNCSSCONNFCT PEPAIR ❑VAPOR ENTRACTga WELL <br /> ❑NAw❑A.. H.P. OEFNF i'UMP SET_rt. TDIST WATER LEVEL D <br /> I—C OF RUM% <br /> 1:1SVT-0E-SERNCE WELL ❑o[oFHYMCAI wN-4e ❑ eorc eowNB B <br /> $(.RTRDCTIOH:� <br /> NTUTI TVR aF WFµ _QN f T N­­­p...MA ONb A <br /> M❑I,NxnrrIML ❑ORNeOTTOM DIA.OF WELL EXCAVATION Wt OF CONDUCTOR CASINO O <br /> y—EITTICIPRIVATE ❑GRAVEL PACKIBRE TYPCOFCADINGRTEEUR'VC DIA.OF WELE CASINO D <br /> ❑PGBLICIMOMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPFC*R ATION A <br /> 0 INAFlATION,AO ❑OTHER GRDUT SEAL INSTALLED BY GROUT 15 A NAME E <br /> ❑MONITOFNNO GROUT BEAI_P—DI❑Y.F 0N CDNCRETEFFDFBTALbYDR&tFR:❑Y,N ON. S <br /> APPIIOX.b w O/ LOCKING CHESTER BOKISTOVE RPE s <br /> NIOMSED CoNsTnUCMNSJFFWNO MEnF MuO RoTARv AIR MTARY AWED CABLE OTHER <br /> INE BY CERTIFY THAT I HAVE PREPARED THID APPLICATION AJq THAT IHE WORL WILL BE CONE IN ACCORD-WE WITH BAN"AMIN CONTTY OtIDINANCEB.STATE LAWS.ANO MULES ANO <br /> REGULATIONS OF THE SAH"AWN COUNTY.HOME O Fl OR LICENSES AGENT'S SIGNATURE CUMMRSTHE FOLLOH :'1 CEFFTIFY THAT IN THE RFFORMANCE OF THE W W FOR WHICH <br /> THIS PEANUT IS ISSUES.I SHALLNOT EMP OY RRSONS SUBJECT TO wOREMAN'S COMFFTISATION LA B OF CAUFOmIA,-CONTRACTOR'S HIRING OPBII"1CNTRAGTINO aIONAryFF CERTIFIES <br /> THE FOLLOW'INO I CERFNY THAT SI H PERFORMANCE OF THE WOR:FOR WHICH THIS FSRMR IB ISSUED.I SHALL EMMGY MRMN8 SUBJECT TO"BRAIAR'b COMFFtEb}TION LAWS OF <br /> CALfGR11 NE CANT I 1'A--ANCE FOR A.RFOMRFD I. I.ATCN SIMTIETE puSxnNO AT LOWER <br /> tLOt MM IUFrF Ie ssYTl LBW 'SP <br /> 1.NAMES OF SIRETS OR RODS NEAI1ESf lO OR BOUNdN6 11IE pppPEflfv, A.LOCATION OF HOUSE BEWAOE fNBMSAL SYBtEM OR PIgMBEO <br /> l }.OC TUIRE OF THE PRORRTY,GMND DIMENSgN8 AND NORFH DNRCTNIN, EXrANSIDN OF SEWAGE DISTOBAL SYSTEMS. <br /> N( 3.DIMENBX]NEO OIRINIES AHO LOCATWN OF AI.L EXISTING AND PHOMBED 8,LOCATION OF V 11 MTHRL M 11 OF ONE INFmHED FITTY TT. <br /> 1 BTR UFIEL INCLUD HO COVERED AREAS SUCH AS PATIOS.DRVEWAYB.AND WAM8. ON THE MKM OR ADJORAHO MrfF Y. <br /> �l <br /> Y <br /> ;T <br /> / f OFFARTMENT USE DNLY <br /> AAPBCFIkn AFxmltl er 'l-�T,(„I� o.n A��l-�•P <br /> R'_A­1en BT DRe —,_­INH BY DAM - <br /> Oxlruetlm lrAp.ctlerl er Ktv.r-�Q o.F. ���,S <br /> /�^T <br /> uNTINO ONLY: NOR FACE ��I I/ <br /> K cmint FEE INFO AMOUNT REMITTm xECKIA" x Fim"O aT ►fIMTfBFIMCE REGLRIT NUMIMR ITIVOICf <br /> D !L /SOS(a L <br />