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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUJN COUNTY PUBLIC HEALTH SERVICES O <br /> ENVIRONMENTAi.HEALTH DIVISION Fly <br /> r 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)4ea-3420 <br /> NON-AFFURPARILk PERMIT EX RES I YFlIR FROM"NIE ivaiian <br /> tEamp1EM 1n TripReehl . <br /> APPMATION M HERE BY MADE TO THE SAN JOAOUN COUNTY FOR A PEPMH TO CONSTRUCT AND"INFTALL THE YMRL DESCRIBED.THIS APPIICATIOPI IS MAbE,N COMPLIANCE wn I)SATP <br /> JOADVW COUNTY OEVELOPMENV IDLE•CHAPTER 9.111 6,3 AND THE VTAMArg6 OF SAM JOAOLRH COUNTY PMIC 14MTIJ SERVICES,ENVHONuENEAL HEALTH OMAOM. <br /> I <br /> JOB ADDREeaon ArmE .3 B 1 i eTrr f�t-E/ PAft t sIxT�Aner ?C f+ C <br /> e _ <br /> DvvNER'e NAME AOL/1Eoo p Q. 00 Z �g��F�E��` � 8 <br /> eDHERAeTan pLAILL �.' <br /> ANTNIESB •Q -- j RHONE s� L��j <br /> PUB CONTRACTO. ADOfWDO UCF PHONE <br /> rem OF wEL NEW WnL ❑AEFTACEMEM WELL CI MOWONM WELLI I..I.OTFMFI <br /> ❑,NeTALIATION ❑WELL SYSTEM REPAIR ❑cnoBS-CONNECT REPAIR ❑vApOR EXinACTON WELL S <br /> J <br /> ❑IN—EQRAPW H.P, bEPTHPLMPSET FT. FIRST WATERLLVEILp <br /> TTYTE OF PUMP) �r-yy rryy <br /> LJ OUf-0FiERVICE WELL lJ LIEOMWMAL WELL P ❑ SOIL ODRINO a <br /> Q OESTTSJCTpN: <br /> HT Vi T7yTPe OP WFlt CONSTRrrCT10W EFEcstGAhDN/E A <br /> NbUST1eAL L11offN sorrow y OVA.OF WETL fl[CAVATIOj •1"9 4�p VIA.OF CONDUCTOR CA91Ha p <br /> UOMF:1"J.-RYATE Ty"""W PACKMCn I''� Writ OF CAMNOM EIIRVC O EXA.OF WALL CASINO �f O <br /> ❑PILTINX WINICIPAL d . DETRx OF nAOUT REAL_ 1 S-E—ATION6.—0 R <br /> ❑I FIGAT10RfAO ❑OTHER GROUT RAL*WAUID&Y hC 4- ORDUT eftAflO NAME rF-yy E <br /> ❑T.IOFSTOMFVO GROW SFALTVi D:§q Y- ❑NF CONCRETE PFM rAL BY ORLLFR:LJ Yr�µp Y <br /> IUL11a <br /> APPRO;,DEPTH LOCNO ESTVE ER ROXWrOP" '` a <br /> 1 <br /> IROFOS®COWSTRUCTIONRWFLU M METRIC;MUD ROTARY AM NOTARY AUQEA CASSE <br /> 11ERE,W CERTIFY THAT T HAVE FREPAREO TMS APFUCATION AND THAT THE WORE[TMLL BE DONE IN ACCORDANCE WTM SAN JOAUUIN COUNTY ORDINANCES.STATE LAWS,AND RULEe AND <br /> REOtRATIONB OF THE SAN JOAOVN COVNrV.NOME OWNER OR IXENNO AGENT'S SIONATURE CERTPPIE6 THE FOLLOWOW.'I CERTIFY THAT M THE PFFFOIWANCE OFTIIE WORL pall WHICH <br /> THMPUWMTIORAIEO.ISN.4LLNOTEMPLOYPtMNIKMJF&FTOWOIOWAN•SCOMPFNFAnMLAwsaFCAUFOM^k'COMNhCTa R'e HRv�O OR SU6CONFRACTNONRDxwTV nE CE1rt1f1ES <br /> THF FOLLONM/O_ 'I CEATIPY THAT N THE PE ANCE pP THE WE FOR WHICH TIM AIRFAIT to M"*.I NrALL FM"Y PENWMo Suamm TO VTOVapAANY CoMp"MATTON LAW OF <br /> CAUFOFO" CANT 111U CALK>4RICE FOR ALL REOISIIED INSFW110106 Ar I 1 SSFyr.COLM4ETE bRAWNO AT LOWER ARIA FROYIDEv, <br /> 400—d)tT. Lrw. 11317 9 <br /> I IF <br /> ROT RAM 11—m wwt S..1; IF <br /> 1_NARES Of*VFW@ OR ROADS.HEAMST TO On eOVHDIFA THE PROPORY. R LOCATION OF HOUSE SEWAOE OWDIAL SYe1Eu OR ROPpeTD <br /> 7"OUTUMF OF THE PADPERrT,at1040 OIMENeRRK AND NORTH ORECTDN. EXPANSION OF SEWAGE IAePOSAL SYSTEMS. <br /> IIE <br /> S.DSMOSO MO OVILB AHO LOCATION OF ALL EAMTWG AND RDMOFO S.LACATON OF WELLS TLRrHOf MISMB OF TYNE HUNDRED FIFTY R. <br /> STIAlCTVRES,SICLIICE/IO COVETED AIMM eUCH AS PATIOS•DFTVEWAYIL AND WAIXS. ON THE PROPERTT OR ADJOBSNO PROPERT1r_ <br /> W . <br /> a/ J l�ti r r <br /> � r uPE alnr <br /> ApNSAHen AFwpRJ RP <br /> WFrA RwR�rNr.,er D•e. /'�� h.nF IMa.eM.n er OM. <br /> nn..I�runrel.qr,r InTPnllan s 0,1, <br /> E.n:Itr tZlo rREKA4a �RuCK 1 g `Z58EK 5A!vp sr.u,FRy >5?109 _ YS�1S S.RIuAS"Ct1Rle <br /> _Zd?p.4_4r-;:7 ory f`jt err- Abby meReEa doneptm PaNtPr�iC9 <br /> ACCOIJMRWO aXly: AIOF <br /> ZtiY'S our•2rl.rl� <br /> Pe CODES To INFO AMOLNT Ill"171D C%IC"H RLTDVEO IV DATE P9NOTISF7IVICE REOLRST MWIER INVOICE <br /> Oc <br /> 1 +� <br /> 1 <br /> PUO I'ienRll Serv.-ErMrO.173 11l6TJ ^�._.._..__. _ <br /> L_ S� <br />