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- — APPLICATION FOR WELLIPUMP PERMIT _ I <br /> q0 ....AN JOAQUIN COUNTY PUBLIC HEALTH SERVIIP-oL <br /> ENVIRONMENTAL HEALTH DIVISION 1 <br /> BOX 380, 446 N.SAN JOAQUIN ST., STOCKTON,CA 96201388 <br /> (2091 469 3420 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> ICompMt[In TIVIkFt.) <br /> APPLICATION 18 HEREBY MADE TO THE SAN JOAWIN COUNTY FOR A PERMIT TO CONSTRUCT AROMA INS TAIL THE MW DESCRIBED.THIS APPLICATION IB MADE M COMPUANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT TIRE.CHASTER N-1116.3 AND THE ST AWARDS OF BAN MAWIN COUNTY RIBUC HEALTH TERRACES,RACES,ENNRONMENTµHEALTH NWMN. <br /> JDB ADOErsamn AM# Z575-310-7—q- Cm 'TaLy PARCEL SIZVAFN. <br /> OWHERIBNAME Milton Biikham ADDRESS 1697 Wes n 'ONE.835-4723 <br /> CONTRACTOR V & W Drilling AMURRp1Pj11.F(�Y•OYy. BOX 51 LLDI 4 MXINE1�707�374-N5 <br /> SUBCONTRACTOR Fq' AWRESA—y�F "A 94571 UCI RHINE[ <br /> TYPE OF WFWAIMP; ❑NEYJN'ELL ❑rERACEMEM WELL v/WNROMNO WELLFIWO ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM M:PNR ❑CROSSCONNECT REPAIR ❑VNOR EJCT CTRNP WlIL P J <br /> ❑New❑RePWr H.P. OFPTN PIMP SET_". FIRST WATER LIEWL O <br /> (TYPE OF PIMP <br /> ❑OUE-0FBfPVICF VIFLL ❑OFOPHY61CµWELL! ❑ LOLL BOMNO B <br /> ❑OESTMJCTXIN: <br /> INT[XO[0 B[ Y CONSTRUCTION SPECIFICATIONS A <br /> 11 INDUSTRIAL chleNBOTTOM �FCIA.OFWELLEXCAVATION 8.5 MA.OF CONDUCTOR CARDING 0 <br /> 11COMESTICMEVATE MORAVEL PACK/BRE #3 TYISOFCAMNOI6EFFINVC3y1. AA' MKIFINTLLCAMNO 211 D <br /> ❑PIMUCIMUNICIPAL ❑CRAVEN DEPTH OF GROUT SEAL Q4' BPECIUFATION IF <br /> 11Ly <br /> 1 RIAR ATMNIAO ❑OTHER BLOAT REAL INSTALLEDIMM BY IISLRmELI GROUT I NAME 4%B3Lt E, <br /> Ny MONITORING GROUT SEAL PUMPED:y1 Ys 11 N, COMEKMUALWV R: Yr 0. 8 <br /> APMOX.DEPT. V LOCKING C MBTEK EGN BEOVF THE B <br /> RIOPIBED CONSTRUCTIONIOIEWNG METHOD. MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE9 OY CERTIFY THAT'HAVE PREPARED THIS APPLICATION AND THAT THE WORIL Wnt BE DONE IN ACCORDANCE WETH BAN MAWIN COUNTY ORDINANCES,STATE LAWS,AND MILE.AND <br /> RWVLATIONB OF THE SAN JOAOVIN COUN HOME OWHFR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE FEPEOPAIANCE OF THE WgPK FOgWMCN <br /> THIS PERMIT 18 ISSUED,I$HALL NOT EM `'RRBON NIU CT TOWORKMAX'S CONPON.....LAW60FCAUFOMJIA.'COMMCTOfl'B HIPoINI Ofl bBLOMMCE11q 8MNANPF CfRTMEB <br /> THE POLL 1 CFXTIFY TI AT M T PERFONAAHCE OF THE <br /> M= <br /> FOq WIIICN NIB EE PNrt I.IBBVFO.I MIALL EMPLOY PEfl.ONB N6IFCT TO WORAAAMY CO P[MS IRAN UNT OF <br /> CALIFOPNI TN APP CARET ST N MMV IN AWANCF TOR ALL gFd11P ".61 MON lE0[I•Ni13i.COMPLETE OMBNIM AT IOWFfl APEA IRAN <br /> B1FLa X *1 DD 4/f)✓M_//-`/--/-LV- ^/\ DR. <br /> v IV <br /> ROT nAn IMm'le R Se.l. ro 201 <br /> 1.NAW-OF STATUS CAMPOS NEAREST TO Oq BOUNCING THE FROM V. A. LOCATION OF MUSE SEWAGE ONSFOM SYSTEM OR PROPOSED <br /> $.OUTLINE OF THE IYMMITTY,01NM DIMERI MM AND NORTH DIRECTION. EXPAMION OF.EWAOE NOMSAL SYSTEMS. <br /> 3.DIMENSIONED OUTURFS AND LOCATION OF ALL EXISTING AND P UM.ED S. LOCATION OF INT118 WITHIN RADIUS OF ONE HUNDRED FIFTY <br /> STRICTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,OPoVFNAYN AND WA'R8. ON THE MOPERTY OR ADJOINING PROPERTY. <br /> FAt1Z1'Bd Rp <br /> DEPARTMENT USE ONLY <br /> AFPINellen A...BY OR. 1•I L e r� Nr i <br /> Orou Inpeellen By O.Ie P—P I-11wR By Dem <br /> Orelwn0�L.PR/BIRI BY �D.M <br /> ceRR.IN: J'TEIQSS � � Y 1000 [^t"W/"t.fC/LV'Y' <br /> ACCOUNTING ONLY: AUH FncF <br /> P CODES FEEINFO MROORE RdIRED CMCKFICASIL I .-FIEDBY DAT[ PFRMITISERNCF FURRI-T WMSER INVOICE <br /> 3 D gt2i� b 5 mo q-14 0121 <br />