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APPLIC JN FOR WELCJPUMP PERMIT <br /> SAN JOENVIR COUNTY PUBLIC HEALTH SERVICES &GINAL <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202(209)468-3420 <br /> AOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED - <br /> Ic.mpMb Ie uylm.Al (I I <br /> 'P`HI AHGN IR HERE RY of TO"IF SSRI JOAOUIN COVHry Too A PERMIT TO CONSTRUCT ANOTn INSTALL THE WORK DESCRIBED.THIS MRICAIIONIS MAGE IN COMPLIANCE WTI,BAN <br /> MAGUIN COUNTYDEVELOPMENT TIMIU.CHAPTER 9-1115.8 AND THE STANDARDS OF BAN1MAOVM COUTNTYPUBLIC I IEALTII RERNCES,MN AFVMEMAL HEALTH VGG=N. <br /> 1.1 AOORESSNR(�A/VN�I� �.�)J/��� L C �.1 CITY 1 vcL cc PARCEL ODEJAMN <br /> OWIRP'.NAMEAyy(lLE///TII/MS�vr �FQ�-�• it57�/N AFTER..-, It LT+b\ .S i-reef I.mNER ao9P3s�`h37 <br /> COERACTO.W(I3ht �E Q,v I,njVn 1 aL.R�+�woDEBe b�1 �. rD lh Stre.'t uc/�SI SOI MDE/aC19Y 33c�-t S� <br /> .U.COERACTon f�(LC�YfL M Ao.r¢ae 33bS WE'L.l'Q[e1 IACD 51224�Yi MovE/a YFil x'112 <br /> TYPE OF WEIN'IIMr' ❑NfW WfLL ❑RfMCfMFTfI WDLL ❑MONI\ORINO W[Lt I Tllfn � <br /> ❑INEALUTION ❑WELL S1S1EM REPAIR ❑CROSS{O NNECTIIE rAIn ❑Vw10PFPTMGI NWfLLI J <br /> 0 N 014oe1r N.P. DEPTH NMP6Er FT. FIRST WATER L[VEl O <br /> "Y',or Fear, — <br /> ❑OUrODBERVICEWELL ❑OEOMIYSI[AI NRLL/ ONNOB <br /> ❑O',H.CTHR, I <br /> IMIFNpEO ell TYPE OF WELL CVNi1PIIGH.M/r1C111.AH.N. A <br /> ❑HGV.GYAL II.M.ROROM VIA,OF WELL EXCAVATION VIA.Dr CONOVCTOICASHIO IT <br /> ❑MNFBIDRFMVAIE ❑..VEL FACRI.11E IIDE.ICASINO1.111 VC DIA,Or WILL CASINO O <br /> ❑hHat RHONICIPAL 110. FN DEPTH OF GROUT SEAL M4CIFKAIION R <br /> ❑IRNOATR N/AO ❑DINER GROUT SEAL INSTALLED RY ORErt SONO NAME E <br /> O MONNONNR DGo VT SEAL NMI D:91- (3 CONCRETE PEDESTAL By owuw:0 w ON. A <br /> Al...DINT. U,cK,.G enee.En eoXlPwvE SheII S <br /> MOMSM CONSIRUDIIONmNLUNO MUHIND: muD norAnv IR Lamm AUGER GAME OHeVNt'C - LSI+ <br /> I HERD MY CMI ITY TI IAT I I LAVE PREPARED THIS AT ATION AND THAT THE WORK WILL PE CONE IN AC[ PRANCE MTN SAN MAOUIN COUNTY ORDINANCES,RATE LAWS.ANN PULER AND <br /> MTNULANONB OF TIRE SAN AOAMINCOUNTY.HOME OWNED OR LICENSED AGENT'S PDNANDE CINTHEMES111E FOLLOWWG:'ICERTIFY THAT M THE 1EWOOMANCE OF THE WOK FOR WITH <br /> IIS.I'EGAN,IR MDU...PN."DOE EM0.0Y PI...'ECT TO WORKMAN'S COMPENPANON LAWS OF CALIFOPJIIA.'CONTRACTOR'S HIRING OR WS CONTRACHNG mONRTVE GESTS"S <br /> LITE FOLLOWING: -I CERTIFY THAT IN TIME FEMOPMANCE OF THE V oM FOR WHICH THIP RRMN IP ISSUING.1 SHALL EMPLOY DEMONS SVSJECT TO WORMIAN'.COMFOI.ANON LAW.OF <br /> CM.UORMAn THF APNCAMI MVPI CALL]A 1pMe (P6�/�NCF FOR ALL RFOUPM,AI,,/ NONP AT IIOPIAMYIf.COMI4ElEVMLNNO MLOWER AREA NDNOEO. <br /> a,e-1 P Y 11!l v L_.ti._ 1�\/I NR., l I \ i .1 D.I. "�-- '.,cl <br /> 0.0'MN Go_M.1.1 b.1. <br /> 1.NAMr.Of PINE\P OR MADS NEAREST TO OR.OVIIdNO THE RLORPTY. F.LOCATION OF HOUSE SEWAGE DISPOSAL SYEFM OR NDMMU <br /> 1THNF OF THE PFpNNM Y,ORMDIMENSION.AND NORTH WDECTpN EAPAN.ION OF.FWOE pMPhI.VSIEM.. <br /> NO LOCATION OF All'RATING ANO PTgN.M AH <br /> O <br /> CA <br /> , <br /> ..OF WELL.WHIRR MO G.OF O NE RI....1.lert N. <br /> VIND <br /> Una,IELVO COVERED AREAS MUCH AS PATe.OR/tWAYB.AND WALES, ON NIE REVPE Y OD ALI.MNOPROPERTY. <br /> =i i r i s=i-i=r=u �=i=i=i=i=i i-i=i=iii-i i i i i-i i=i-ia i ri r=r i_i i i i"ri i i i I I <br /> W <br /> 11 I .. I I - I•I I L. I • �j � i ;n <br /> I <br /> (r] I <br /> - I <br /> I I - <br /> I <br /> I 1 m <br /> I I <br /> II Ej t <br /> 11 � -II _ -- <br /> DIF—TMENT UPE ONLY z <br /> AnPIIVN4.AeeglaA PYA <br /> D..N wnQILA eT _ml TLDn'1 11.1 er DFI <br /> O�mnll.n Fwnrllm eY <br /> cA.m Q 3 <br /> Me <br /> AC' <br /> leeeo E.HO NLITTIN'. AMOUNT ROFtTFO CHECK/ICA.. REC.VEO.1 a." '.NRFENCE A'..'NW.VI Q� <br /> p 5 Z-18DO2f <br /> Poe.Health$BW.-EDYUD.173(W) " <br /> l <br />