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P. 3 <br /> 11-12-1997 9:04AM FRO' <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95242 <br /> WD)40-3420 <br /> "*W91QASL�N EMIMs f YEAR MIN VAT[M1119 <br /> 1C pl to Is T11pfatel <br /> AN,t=ATON M HEM 1Y MAGE TO THE SAN JOAMN COUN"FOR A FMor TO COHWMICT ANDPOR MMTALL THE WOW DEICISSED.THN MKICATWO M MAOI IN COMNWICE WTTN u <br /> JOAOUIN COIMrY DEVROPMWr T1TL.CHAPTER Y-1115.3 AND THE ITMOJWf OF SARI JDAMM!COLWTV►LIMYCC NEALTN a6RVICE1.114YONONUDITAL NEALTH OIq�oo". Li <br /> )Lj 0 <br /> FAmmulm <br /> JOS ADOII1SSIOR APNf - <br /> y� <br /> OWNSII'1 NAME u � -^ '�r�7'�•t. �..1��.�'- �� PIIOHE f <br /> OONIRAOTOR (� �j f �S?� r A Lr ---AOOPE t 1,7 i A v %C c•r l7Cf � L Pmm ou- <br /> 11L1 CON►MCTOR�/ t� I A00111a J .rte UC! PNOW f <br /> TM OF mmmm ❑ mew WELL ❑ Par Amww weLL ❑ MONRoRMIf vinL f ❑OTNp1- <br /> 0 SMTALLATION D WELL WAMW RAMI ❑arose owacT MFA1R ❑ VAPOR CtTMCTM WELL f <br /> © DEPTH PUMP SET R. FM T WATER LIVR. <br /> f1v"OP PUMPI <br /> ❑oLnoafnwteE Well D OBOPIMeICAL WELL f O wa 1pRwm <br /> A off, <br /> ❑ wwoTISAL ❑Open BOTTOM OSA.of wet EXCAVATION DIA.OF CONDUCTOR CASM/O t <br /> D DOM OM PIIVATE 0 GRAVEL FACKM22 TYPE OF CA1N0/ITEDPW OSA.Ds WELL CASON t <br /> ❑MOLICAAM MWAL ❑DISVEI/ DEPTH OP GROUT am sFEL MICATION S <br /> ❑ wasATOWAf ❑OTIRR GROUT PEAL 00TALL10 W SSOUT BRAND NAME E <br /> p ,owmm,,II sRovT SEAL NLIAreDI O Y.. ❑N. DONL Rcr[Pcocs.AL w omjj*❑v.. Do. s <br /> APPRO .OwtN '"4L WCRN19 CHESTER BDXMrow Pm S <br /> ITIOPeM CpN1THUOTgN1DMJJM MfTNOOs MUD NOTARY/ AMI ROTARY At1M <br /> I NE'IEBY CERTWV THAT 1 HAVE PMPAWO TWO APPLICATION AND THAT THE WOW WILL IN DONE ML ACCORDANCE WITH SAN JOAOVMi COUNTY OMNANCES.STATE LAWS.AND AM$AN <br /> MGULATONS OF THE IAN JOAO"COUNTY. HOME OWNER OR LICENSED AGENT'S NONATUM CERTIIYES THE FOLLOV MW:'1 CERTMY THAT Mi THE PIWORMANCE OF THE WOW POLI VNRC <br /> TM PFF MTT IS 111UED.1 MLALL NOT EMPLOY PERSONS SURLECT TO WOMMAN'S COMPIRMATON LAWS OF CALM'OIMMA.' CONTRACTOR'S WIMM OR SUB•CONTMCTBLD 0"AWN CWTIM <br /> THE FOLLOWMIO: '1 Cl1RIFY THAT IN THE PEIVRW#AAI/CE or THE WORK►OR WHM.N TNM Pe1MAR N/SSUE'D.i SHALL EMPLAY MwomS SINJECT TO WORMAAAN'S COMPMSATIOR LAWS o <br /> CAlXO1MSA.' MI <br /> T/� ANT NT CALL,24 HoURS TN ADVANCE POR ALL VORKOW WSP901101/1 ATM �SM•SS2S. COMPLM DRAY MM AT tAVAP AMA PIIDIRDED. <br /> 0 1 X <br /> MAY PLAN Lb. a 1..1.1 5..1. •a <br /> 1. NAMES OF STIRETS OR RDA»NEAREST TO OR BOUNDOM T11E PROPERTY. f. LOCATION OF HOUSE SEWAGE ONFOSAL SYSTEM OR MWOSYO <br /> 2. OUTLINE OP THE PNDFERT'Y.OPANG orw"IONS AND NORTH OMKCTION. MWOM M OF SEWAGE M SYSTEMS. <br /> 2. MMMMM OWLINES AND LOCATION OF ALL O MTMM AND PIIDPOSED B. LOCATION OF WELLS WITMN RAMM OF ONE NUNDAW PIF1V R. <br /> STIEICTUM.MICLUDWO COVERED AVE"SUCH AS FATO1,DRIVEWAYS,ANO WALRR ON THE PROFDLTY OR ADJOOMM PROPERTY. <br /> ' .....:.. .i......'......: ..i....i . i : ...i.....i <br /> ....... ..:...i...........I....y...... ..I..............p.........................E......j...... ..... ......e......:.. ...3............ ...i.....y...,..�....:i.....i....._......�..._..:=a. ..e......j.....�. <br /> fE►ARISMBIET u1f ONLY 0. /q/7L <br /> '7 <br /> ASSN..r.n ASwSId h^, <br /> 0NIIt 11Y1Stltd►fP D.I. Pow MnP..Il.n ST D.L. <br /> Cw�wmMu <br /> ACCOLM"MG ONLY: AID/ FAC# <br /> R Coop FEE tNI'O AMOUNT RIMMED MN 1MORV W SY DATE PINVATISWIMME R40UEST NURmR BMOICt <br /> EL <br /> Pub.Health S11Y.-Err*o.173 Offln <br />