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APPLICATION FOR WELIJPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> N0N REFUNDARLE PERMIT EXPIRE!1 TEA I FROM PATE 129VID <br /> Mm"plRtR In 71IpRnttl <br /> APPVCA 7PON M HERE RY MADE TO THE SAN POAOUW COUNTY FOA A IE It TO CONFTMKT AWOR INSTALL THE I$SB APPLICAIHVN IB MADE IN COMPW.NCf WITH BAN <br /> JOAOUIN COUNTY DEVELOPAlNT TRLE,CHAP7M 9-1116,3 AND THE FI ANDAADS OF RAN JOAOIXN COVNIY PUMJC HEALTH SEMACES,EWoONMEMAL KAtTH D wow <br /> JOS ADOERN�OR APNE1� }T�y�� il—d CITY (�C PARCEL MZF/AMN, <br /> DWNFR'f NAME_ `L�/._W!jI� (]^.., y1 p _ADV/E.. e. PFMFEE. (3 <br /> CONTRACTOR_ �C/ 1\ Y i Y1._] ��...x lT� J\1�.`y{f'� AOORFB (Af,4f,ICI �IMON[/ r� �{D <br /> IItAHIfMIVrCTO� AODRESf Lief "-- FNONE f <br /> TYPE Of WELLAIUMP, ❑N. WELL r❑TEPIACFMFNT WELL ❑MawomP WRLL f F❑y O7HER <br /> Cil , ❑NB•AllAigN u �/B�TFM IEPN1l ❑CbSB� C7 IEPNR tJ VAPOR EXTRACTPJN WFLE/ J <br /> Irl yry� iw-_L -.w N.P. 1 !i^► OFPfH Pl1MP BEY FIRBT WAT[A tfY_% �-- D <br /> O YP[OF 11 HIR�� F-t—`� <br /> EE----�1 a OUT-OF-RERVICE WFIL ❑nEOPIYOCAL'NEtL/ ❑ S01L FORN'J <br /> GMMR�EIfiiE01/w w `�+ <br /> f-t <br /> IR 6TOEp VRe FCyyK W US IoM A IONS A 1�.I <br /> ❑—67MAl LJOPEN DOITO?A DIA OF WELL Ex CAVAi1ON DIA.Of CONDMtXtOR CARINO n <br /> M DOME6T$C"l Alf (j OMVEI PACKI ZF _ IY14 Of CAI11NOlBI FFI n•YC pA JF_RL CAMNO D� <br /> ❑PVRIJCMUMCtF4 �E-JE DNVIN OEPTH Of OAOVT BEAT WECIIKATIDH <br /> ❑AVEOATIONlAO ❑OTHEn ORDVT SM NOT <br /> ALLED BY NIOVT MRAND NAME �T F <br /> PIFf <br /> ❑MOERTOP)No OROVT PEAL PINARD-❑Y— ❑Ne <br /> APRROX OF —`ONCIET[PEOfBTAI BV fNW1Ell QY•• IJN. <br /> PTN to"Mo CHFIFT[R MoxmOV[ s <br /> P MOW CORBTIRMTroR/DMLUNO METHOD! MUO RDTMY AIR ROTA" AVOEA CARE OINFII <br /> I HE•NNV CERTIFY SHAT 1 HAVE PREPARES TME APPLICATION ANIJ THAT TRE WORK WMIl OF DONE N ACCOROANCf WRTII BAN JOAOUtN COUNTY OIOINANCEf,WTATF LAWf,A-RULER AND <br /> REOULATIONR OF THF RAN JOAOtIRI COLWrY HOME OWN[A OR LICENfFD AOENt'S fONATIRE CER7fTlFe 1N!FOILOYAq:'1 CERTIfv LNA7 M TFE PFAOPt1AfICF OF TLE WORK POR WRAC <br /> 11RR PlRMIT 111'RUES,l WILL NOT EMPLOY PE7190Hf fq/SJECT Iowco MALME•S tOMfENtATION LAWS of CMIFORMA,'CON'TRACTOIPS EIIIE/IO OR RI6COM MCTDNI SIONAIIHIf C[RI FIE■ <br /> THE FOIL -1 CERTIFY THAT 1N E PERFORMANCE OF THE WORK FOR V\•RCH TEM REMRT 10 W"D.1 FNAAL EMPLOY PERBONt VL)"CT TO E K MANY CO FOPM N LAWS . <br /> CAINORNPw. TK N'PLPC T ML1fT N Ibew N ADVANCE FOO ALL REOtlw1O 1 TOtH AT T""AEBJnff.COUM"I CWIAY IO AT 101*1p1 AREA ASO [� <br /> bfrNf X TRIM 1 0.1• <br /> FEOT MAX prRw Is C•M•I f•W 'ro <br /> 1.NAMES .EIS OR ROAD"NFAHESUN <br /> T TO OR MODNO THE E7IDPERTY. '-- 1, ATPD"Of HOUSE NWAOE dSPOf AL SYFTFM OR PROPOSED <br /> IN <br /> . OUTtF M 71W PROPERTY,ONMIO DIMFNBONIE AND NORTH 13PMCTMN. EXPANSION OF*FWAW DHBPOBAL SYSTEMS <br /> IME7. DNKONED OVTt1PFE AND LOCA Of ML E.Irf Ir O AN0 PEIOPOND F. LOCATION OF WELLS MINNW INN MUNE OF ONE HUNDRED FV TY fT. <br /> ■TRUCt URE',NCLUTANO COV[RM AREAS SUCH AS PATIO{,DMV[WAYS,AND WIALAF, ON THE PROPERTY OR AOJOS/M/O PROffRfY, <br /> e� <br /> Z <br /> 6 <br /> PAYMENT <br /> p RECEIVED <br /> Q- AUG 2 6 1997 <br /> 11 T' _ - SANJOAQUINCOUYTY' <br /> 4 SO pUBLIC HEALTH SERVICES <br /> EMMONMEW AL HEALTH 01'4Z k) <br /> I- 1 <br /> OOAMMENT USE ONLY <br /> AP►fe. AN•PIM FY D,A• �* A�,, <br /> O.•.A kAeb1l•..M D.1• ILnP InRPA•II.D fE �7/ D•I• / <br /> ACCOVNOPM ONLY: ARN IAC♦ <br /> P[CDOV, FR INFO AMOUNT RDMTTm HU" ASH RfCQVED MY D TM PEIIMIYMYLbTCE RROUEPT MUKOI R IRR/OIC! <br /> o o S a <br /> OLM <br /> Pub HeWth SeN.-Emlro173(1/97) <br />