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APPLICATION FOR WELUPUMP PERMIT <br /> �\ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NON REFUNDAILE PERMIT EXPIRE$1 Yam FROT$DATF 1$$UED <br /> ICmmplate In Trlpkw`I <br /> APMICATION M HERE BY MADE TO THE SAH JOAClUIN COUNTY FORA PrNmAIT TO CONIITRUCT ANDIOR INSTAL(INE WON(DEECNSEO.—d APPLICATION If MAGE IN C'OMPLUANCE WDINSAN <br /> JOAQUIN COUNTY OEVELOPLIENT TALE,CHAPTER 2-1115.3 AND THE SIANOMOS OF RAN JOAMIN CODUN'TIY PUBLICIl[ALM SEINIC[a.ENVI NMEMAL HEALTH CMBR/N. <br /> Z.AOOM."R AM' .0 /� � ' _CI(Y (/'.�dS J rAPCELR4EIAENI <br /> OWNER•sNAME <`p�-1 - .�n,t'. AODREse 7�O� <br /> (' ��� �) l T/� TIIONEI <br /> cDM RA[taR � XNE e■ <br /> I!J -_C!h NNIS SF/LF:< �'. AI ` :7 JIA .`/ ms "mw �3G-%/i(s <br /> FVB CONTRACTORIIryry AOOIESS - L1C/ PIMA F <br /> TYPE OF WXUJPLWP, 1J NEW WELL ❑REPLACEMENT WELL ❑NIONRONNO WELL/ ❑OTHER <br /> ❑INVTAILATNC* ❑WELL SYMTEM REIMR ❑CROMM CONNECT IEIAIR ❑VAPOR TX IRACTION WALL/ J <br /> su b ❑Nw. L.FIM N,P�,�L DFIN PUMP BET J�-,FT. FTfF WATER LET..L.2aI / <br /> aYPE OF FvLN`, R-� .� <br /> ❑OUl ORSEINICE W'F(L U OEOMNV810N WELL I ❑ @0A,BORING / j ••// <br /> ❑OfSTRUCTION <br /> l, <br /> W TEJIDID USE TY ELL COMSTRlA:110N FP[CIFICAIpM■ A <br /> ❑IwwffTNAL ❑OFEN R.orTOM DIA.OF WELL fXrAVATLOH OIA.OF CONOUCTOM1 CARR. Dir•I <br /> ❑OOI.FEVrIC1PIEVATE ❑OMVM PACKI0I2E_ TYPE OF CAMNOIRTFFt— OIA.OF WELL CASfNO D L f <br /> L l <br /> F❑'1 gleL1C1MUNICB•Al EU-�DNVFN pFPIH Of O5K1t1T—L _ eIACIFICATION R <br /> U ILROAIKWIAO OOrNLR OROUT VEAL N ALLFD DY ONOIFT BRAND NAME ( <br /> ❑MOHITONNo OsF VT lM-V D:❑ ET <br /> Yr ❑N. CONCRE IEIIESTAL SY bFBLLER:❑Y. ❑N. s I`1 \ <br /> APPROX.DEPTH LOCRRJO CIIFMTTR SOK/ETOWE PIPE s <br /> PROPOSED CON@TnUCTLURRINLUIO UFTIOO:MUD ROrARYT_AIR AOIARY AUGER_CABLE OTHER <br /> •r <br /> 1 HFg BY CERTIFY THAT I HAVE PREPARED TME APPLICATION AND THAT-'HE WOM We.L RE DONE M ACCOPDAN'_E WTFN MAN JOAOUIN COUNTY ORONANCEB.STATE LAWS,AND RULES AND <br /> IIEOULATIONS OF THE SAN JOAOUIH COUNTY,HOME OWNER OR LICENSED AGENT'S NONATUIE CERTIFIES THE FOLIOWRNW'T CERTIFY THAT N THE PEIf0104ANCE OF THE VIDIFL 7011 WNKH ,` <br /> IIRM PFRAAIi h IMSUEO,I SIAL(NOT iMROYI'ESaOtM SUeJEC7 TO WORFJMAN'F COMPFNFATION LAWS OF CAlEOIMA-'COMRACTOM1'■MIlq OM1 SM{ONTRACTINO SGNATVRE tE1RIFEB `� <br /> THE FOLLOWING: I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH TMS PERMIT IN ISSUPJ,1 SHALL EMPLOY PERSONS KUEIECT TO FFOR.AAN'S COM►SHATION LAWS OF <br /> CAMO/EIA.' TFI� KKANT MVSF CAIl Id 1 B nF ADVANCE FOA ALL MOUNIEO NSINICTIONSaA AT waw IYJSSf. COUMj1E DRAWN"AT LOWER AREA PROVED. (� <br /> TIM <br /> V.r+d K---r <br /> ROT PUN IUr I.e.r.l Re.1. 1. —� <br /> 1. <br /> NAME OF STREETS OR"DADS NEAREST TO OR SOlNDNO ME PRDRRRY. L. LOCAMN OF HOUSE SFWAOE DISPOSAL BYSTAM OR POOrOSEO \ <br /> OUTLINE OF OF TM MNB PNOMPTY,ODMWWWONS AND NORTH UIIECTIOK EXPANSION OF SEWAOF D40 OM SYSTFMS- <br /> ],DIAENSIONED OLITLJNFS AND LOCAMN OF ALL EXIITNO AND PI O OSLO F.LOCATION OF WFILM W RADRNM OF ONE HUNK D FIFTY FT. <br /> STRUCTVIEM,NCLUONO COVETED MEA@ VXH AS PATIOS,DNVEWA.YS,AND WALX S. ON THE PROPERTY OR ADJOINNO PROMPITY. <br /> f <br /> oclv:fRl•:. . <br /> •I <br /> DEPART T USE ONLY <br /> AFFV..IN.R Ae.W d BF_ G L C D.. O I L c <br /> ORM FrP.ER.n eT, O.N RIX.IrRF.<Il...eT <br /> D+.Incr.n IrwP.ell.n s• DFr. <br /> -z -,5 ae JW tb4QeD 7b <br /> r3,13-�ND 4��tt, fptfiRti t fel',. — u. o <br /> A—C JN NO ONLY: AID/ FACT <br /> F <br /> —VE. FEAINFo AMOUNT RDATTM CHECIV AFH R[CDVEO■T DATE P9EINTIFFAVICL REOUEMT"WNW 1-1S�•t! O *3(vloo L6 a Ib/98 <br /> Pub 4eetth So".-EmirD.173(1;97) ' <br />