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• APPLICATION FOR WELLIPUMP PERMIT <br /> ��'^ • �,.AN JOAQUIN COUNTY PUBLIC HEALTH SERVII. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST.,STOCKTON,CA 96201388 <br /> (2091 4883420 <br /> M4R-REFUMDRRLE PERMIT EXPIRES 1 YEAR FROM RATE ISSUER <br /> (CPmpMb In TripRPlI.I <br /> APPLICATION In HEM BY MADE TO THE SAN JOAOUIN COUNTY FON A FEUMR TO CONSTB T ANGIOS INetALL THE WOW DESCRIBED.THIS APPLICATION In MADE IN COMPLIANCE WITH BN! <br /> "AWN COUNTY DEWILORAEM TffM CHA➢TEB 8-1116.3 AND THE 6TANOASDS OF BAN JOAOUIN COUNTY MOM HEALTH SEWCES.ENNBONMFMµHEALTH DIVISION. <br /> JOB ADDRESS...1 ZSS-3/O — Z3 Cm Tracy PARCEL ISMARlP <br /> OWNER'S NAME Muriel Jones ADDRESS 31448 S. Hwy 33 NIONE! 835-1401 <br /> coHEMeToR V8 W Drilling ADDRESS P. O. Box 51 IJCE720904 PEIONE;707)374-M <br /> SUB CONT.ACTOP IO ADORE IS Rio Vista, (A 94" MIT PHONE I ! <br /> TYM.F W4LL?UMP: 0 NOM WELL ❑REPLACFMEM WELL :q MONFTORINO WELL I 1 4£11 ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑C...-.ONNECT R1.. ❑v.REETMCEIONwSEE' J <br /> ❑Nw 11Peponr H.P. MITI,NMP eEt_FT. FAST WATER LEVEL O <br /> RYR OF MMP <br /> ❑OVT-0E-SERVICE WELL ❑OEOMVWCAL WELL I ❑ R00.BORING <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION! A <br /> ❑INOUBtRIµ ❑OPEN SOTME1 DIA.OFWFLLEXCAVAWN 8.5' DAOFCONWCTORCA8M0 O <br /> ❑OOMEST.bIVATE 4ORAWLPACIImZETYPEOFCA&NO/BTEELPVc 40M DIA.OF WELL CATINO 2" O <br /> ❑MBLICMUNSCPAL 11 GME. OEPIHOF GROW Aµ 041 SPECIFICATION �L' R <br /> ❑IPoUOATIONIAO ❑OTMR GROUT BEAL INSTALLED BY 'IY]IIRIET amm TEAM NAmEComn J 4CCB]]��Bat E <br /> 4Q MONHONNO GMVT BFµNMFEO:®Y. ❑NP CONCRETERF➢EBTµRYONUEII:GY— 13W S1 <br /> ...A.OD R 0' LOCXWn CNErtER RO.BTOWnPf 8 <br /> TPUMSW COXBTRI.TNINIDIEWNO METHOD:MUD MTMY AA ROTARY AUGER CABLE OTHER <br /> I HEAEBV CfflNFY THAT I HAVE PREPARED THIS AAVCATON ANO THAT THE WORK WILL BE GONE IN ACCORDANCE WITH SM MAOUIN COUNTY OPDINANCEe,STATE LAWS,MO RULES MD <br /> PEWUTIONS OF THE SM MAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK MR WMICN <br /> ITT.PERAN,B ISSUED.I SHALL HOT EMMOY NB SUBJECT TO WORRMAN'S COMPENSARON LAWS OF CALIFORNIA:COMMCTOR'S"IBM OR BVBCOMSACTINO ARMATURECERTIFIES <br /> THE FOLLOWING: ICfflFIFV THAT IN TN REAN[F OF RIE YAINTO.WHICH TIIIB KFAUT IB ISSUED.,WµL EMPLOY MRSONS SUBJECT TO WO11.AM'! OMPOIIAMXIAWB OF <br /> CAUMPES f APBECANT/yE/q!T/r/�D,{. NpW IN AOVtANC!F011 ALL REdSSOM I RCTIO:I T 1' II.Ni4A].COMBRE GNAWING AT LOWER ARFA DEO <br /> wa..AA�I-F'/.i.1.r 2C/�/ ml.�l�( i//M?/.��4�4YZy).EL_ ..I. <br /> ROT RAN RT.Cd.IN BeM. '� •R A�AJ F <br /> 1.NAMES DF STREETS O. MEANEST TO O.BOUNDING THE PROPEFTY. A. LOCATION OR HOUSESEWAGE DI6PoIBµSYSTEM <br /> O.R.PoBEO <br /> E. OUTLINE Of THE R RTY,FEVING DIMENSIONS AND NORTH DIMCTION. EXPANSION OF MAGE d µSYSTEMS. <br /> ]. LUW AND LOCATION <br /> IONOFALLBTmO AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONNUNp1fp LIT'FT <br /> . <br /> STRUCTURES.INCLUDING COVERED AREAE SUCH ASPA110B,OPVWAYB.AND WALKS. ON THE PROPERTY OR MJOININOPROPERTY.TY. <br /> �I/�L�,I(�T/1I� ��✓/���j� DEPARTMENT wf ONLY <br /> APMI-111 A'Wt tl BY <br /> O,Pu:Le v-.r D.T. AmP NUIr.c.Pn er Gone <br /> Os1.,slun,n.P.A.OPO er CC Gone <br /> CPmmml.: 5�" 'o'n {L(q ft, 100 fur-h4po <br /> ACCOUNTING.HLT: AIDS FAC' <br /> PE CODER FEE INFO AMOUNT RENOTTED CNECAI.A.N FS....1 DATE PFREATRBIWCE RMIEET XUM.[fl INVOICE <br /> 5bl 0 355 A 1- S <br />