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- APPLICATION FOR WELLIPUMP PERM T <br /> ! SAN JOAOUIN COUNTY PUBLIC HEALTH,SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION I <br /> ! P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTOli, CA 98201.388 <br /> I (209) 488-3420 I <br /> i NDN-REFUNDABLE PERMIT EXPIRES I YEAR FROZE DOTE ISSUED <br /> (:ompkIA in Ttpl'sBEE) <br /> Aq{KArN)N IS HEIRS BY MAGE TO THE SAN JOAGVIN COUNTY FOR A FFgMIT TO CONSTRUCT aNOIOR INBTLLL THE VVDW DESCRIBED.1.181 11TION IS MApE IN COMPLIANCE WRN SAN <br /> AAOGIN COUNTY OEVELOPJMOFjLEM TRtE cNAFTER 9-1115.3 AND THE STANDARDS Of"K JOAQUIN COUNTY R19UC IIfALTN SERVICES.ENVIROHMCMAL IIEALTH OI VISION, <br /> A9 AOOEE86On AMF .�fl/O' FJ�/(j�F L�'� C.,J�'E�ton <br /> PARCELBI vJ . <br /> mwA•c uu4E f�'+terl Cnn rv/Ie.F'? Pivd✓ef1 <br /> ADsPHO <br /> 8o1 Laesr LAne:f SBOCK"13,C4 ,E4w1,-�00 <br /> If <br /> CONTRACTOR� �AT -�1'.vmrML— AoDFE6S $801anEBldd ,s✓F�ft'sp"O9 n�i'Vi347-88on <br /> W'q Qs82(O' �J. C9)w <br /> WB coNFRAOTOR ty C/l4l' D/)1)Mj.6 SFE✓y�B V4/l�g l �rP �OPLe}�e /inn a Is I IK•�OT2Gl� vHONE 1 $S2-95S8 <br /> fes' Lra <br /> TYPEOF wSUFVMP: LY NELwI WFa1 !❑ , Yo 0f1w <br /> O 7- Soil �ni, <br /> ❑ DT,AWTION `❑ WELL SYSTEM REPAIR ❑ CA039<0NHECTW.I. VAPORFIITRY TIGNWELLI 9 <br /> I naeyL ❑H ❑HUp4M {X.P- DEPTH FJNPBR_R. R90T WATER LEVEJ. D <br /> rRTFOF WNFI : <br /> t ;I❑ OIR-ORSERVICF WELL ❑ GFOMrSICM wELL/ Iw1k BORING p <br /> 1 DESTRUCTION: <br /> I <br /> IIM TRADED W TTPE OF W ' COni T4UC9v.L'EbFU T1LY5 a <br /> T N <br /> ❑INWRWAL ❑OPER tgIION PA.OF WELL EiUYATON � ` DIAL OF COROUCTORCAEINO O <br /> ❑OOMESTICNMVATE ;KGMVEL PACR/SIZE d T JRI1d TYPE OF CAHNO/et Eflt•K PYG OI A.OF WTLL CASING 4 y O <br /> ❑ PYBUC/MUNCMFAI DDnIVEN OCFTH OFCWUi BFAL eFECNICATONSaeI 41'hreA9 P✓C�/i4oA <br /> ❑ MOATIONIAG ❑OTHER GgUT SEAL INSTALUO BY OROUT BRAHO NAME E <br /> �p MONROIBNO '` CADUT fc.t-,MPEO: OYs ❑Ne CONC...PFOE..- ALHYDRIUEiIOY- ON. S <br /> `AFI DFDTH_rIOI fJ LOCwIHO CHEBfER BO;.BTOVE PPF S <br /> MIOWBED CONBTRLlCT2N li O METHOD: UVO ADTARY AIR MTAF.Y AUGIER _CABLE OTHER <br /> 1 <br /> I HERESY CERTIFY?HST 1 NAV�PP"COU 7X16 Ug1CATpN AHD TNAT THE Yg1A t.:•y BE DONE IN ACCORDANCE wTTH 6IW A40UN!<OUNTV OPDMNKEG;STATE UWP.AND RVLE6 AND <br /> REGVLATIONB'OF THE6YJ J I OWIF COUMTY'.�HOME O Fn OR LICENSED ACENT'S SIONATVIS CEMIFIECTNE fOU NO:I CERTIFY THAT IN THE KASOTMANCE OF THE WOW FORNNMH <br /> THIO PEPMR 16IGG EO.I ONAINOT FM0.nY PERSONG 6VBJER TO MOPwax'F C W P6YiiROR UW5 OF C WTORNM.' COMMC]'OR'6 MMAG OR wBLON19KTING BtlYATUF�CFRTBEEB <br /> THE FOLLM'IHG: '•1 CERDRY TNAT N THE FERMFIA. CE OF THE I00W FOR L.N..TH.a PE41R S.SSJED.14IA,, MROY KRU,,NG 6UsiECT TO MOC311A11'S COMM&AF10N U'NC OF <br /> CAUFOPNIA.' <br /> THE <br /> (AFMIC'Aill MUST CALL!31�HOUN IN ADVANCB WR ALL REAMRED INSFfCTONS AT 1.`PSI 4B0i 6- COMPLETE b"W1NC AT LO'A A AREA <br /> ' PW'.TpEp. <br /> e'aDFB 1[ 11 A7�✓L'� TSN T%�C e r man,cRJr- D.,.. S�I I q� <br /> Il/ m <br /> wnr PEAR IV—..�.N 6e J. <br /> 1. NAMES OF'8T Erb OR W 06 NEAREST TO OR WI)NOING THE PF4KRYY_ 1. LOCATION OF HWS(EEYJAOE DIBW8µBYRE.On PROW:EO <br /> E. OUfUNE OF THE PRO GIVING DI Mi <br /> AND NORTH MRECTMN. EIPANWN OF.6ETVAGE dSWBAL SYSTEMS. <br /> S. OINENBtl HED OVTUME6 A 10 LOCATIOI)OFµL FIISTNG ANO PROMISED S. LOCATION OF WEUt VRTNIH RAOIUS Of ONE... PS.RFT'R. <br /> 6TRICTVPEu,I(CWOING C VF)IEO APEK;6UCH AS PATIOS,OFU E AYS,AND Wal S. ON THE FROPEFITY OR ADJOINING.MtlFERY. <br /> i <br /> ) '`�',,,.. .O,YFL,G,�+.;!�.o� NTT/1 Rpt Li rYc�►coc�T..L.v ,e�,.� S,..,�,� <br /> �n1.e,G(/ Fv�N /-�P.��/T �L�•r P,No�t�.,r� F�G„�� <br /> I <br /> .. <br /> PAYMENT_ <br /> j I <br /> RECEIVED <br /> _ MAY 3 Too <br /> SAN JOAQUIN COUNTY <br /> POEILIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISICn <br /> 04F�TMEAT Ulf OkLT <br /> ACPIbem AUFIe!BT '= _ • DNe ✓ Lf <br /> A— <br /> Gnm Inpa,bn ar Ti Dn. FAP I�Fitbn Br D.m <br /> i <br /> p�F..elinn Ir�eaTlen al PN. <br /> j <br /> I <br /> ACCOUNTING ONLY: MOU, TAC+ <br /> PE COO" FEE IRFj AMOUNT REMITTED CHEC4XA.. REi FNED BY DATE RTRMITrt ERNCf PEOVEOT NLM86E INVOICE <br />