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APPLICATION FOR WELLIPUMP PERMIT <br /> r SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 368,904 EAST maER AVENUE,STOCKTON, CA 95201388 <br /> (209) 468-3420 <br /> fil,�/�Q _ 1 e Q�r_n RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER <br /> e L C (' Komplett M TFIpNeaW <br /> APPLICATION 18 HERE BY MADE TO THE SAN"AMIN COVNTY FOR A PERMIT TO CONSTRUCT AMMR INSTALL THE WOW DESCRSSEO.TINS APPLICATION to MADE IN COMPLIANCE WH11 SAN <br /> SOO JOADIMI COUNTY DEVELOPME/NT,TITLE,CHAPTER 9-11155 33 AM THE DARDS OF SAN"AMIN COUN/TY PUBLIC iff 11 SERVICES,ENVIRONMENTAL HEALTH mvISION. <br /> JOB AOORE88OR API# ��7 .7 EC G L CIT�l�J0 0 3L �l,�/` PAAMFL SIMAPNI <br /> OWNER'S NAME ��/l•I1/Lr _AOORESB_ f�✓��CJG. T/fP �[CN-(/.P G—PRONTO <br /> CONTRACTOR YVI! LIw�_ T �L—N .�. ADOIff88 ���f F .SPIICI RHONE <br /> SUR CONTRACTOR ADDRESS Mo PHONE# <br /> TYPE OF WELIJPIIMP: ❑ NEW WELL ❑ ME CFMENT WELL ❑ MON OMNO WELL I ❑ OTHER <br /> //J1 ❑ INSTALUTION ❑ WELL SYSTEM REPAIR ❑ CROSS{ONNECT REPAIR ❑ VAPOR E TMCTION WELL# <br /> c!�• ❑Nevp`�eeeh H.P. I DEPTH NMP SFT/15:�FI'. FIRST WATER LEVEL/V5 p <br /> RYPE OF RIMPI <br /> -� ❑ OUT-OE SERVICE WELL ❑ GEOMYSICAL WELL# ❑ 800.NORING S <br /> ❑DESTRUCTION- <br /> IN IENDED USE TYPE OF WE CONSTRUCTION SPECIFICATIONS A V <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATOR VIA.OF CONDUCTOR CASINO O <br /> 9MMESTICAWVATE ❑GRAVEL PACMIKZE TYPE OF CASINO/STEEIJPVC VIA.OF WELL CASINO D <br /> WBUC/MUNICIPAL ❑DRIVEN DEPTH OF SMUT SEAL SPECIFICATION % <br /> ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY BMW BRAND NAME E <br /> ❑ MONITORING Q GROUT SEAL PVMMD: El Y. ❑NS CONCRETEPEDESTAIBYOWLLER:❑Yr [DIN. 5 <br /> APPROX-DEPTH �/ �� / LOCKING CHESTER SO%PROVE Nff 5 <br /> MIO#OBED CON8T1111C1mpId0WNG METHOD: MUD ROTARY ABI WTAM AMER CABLE OTHER //'� <br /> 1 HEAERY CERTIFY THAT 1 HAVE PREPARED THIN APPLICATION AM THAT THE WOW WILL RE DONE IN ACCO ANCE WITH BAN JOAOUIN COUNTY ORMIAMES.STATE LAWS.ANO RULES ANO l <br /> REGUUTIONS OF THE BAN JOAIXIIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATUPE CERTIFIER THE fOLLOWRM:-1 CERTIFY THAT IN THE PERFORMANCE OF TILE WORK FOR WHICH <br /> THIS PERMIT 19 MOVED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S MING OR SUB-COWMCTIM SMNATUPE CEMIFRO 1•+ <br /> THE FOLLOWNM: -I CEMNY THAT M TNM PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS MWED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-,COM17 HON LAWS OF <br /> CALIFORNIA. TTN��/Py)IICANTFMUST <br /> /CA/L%2t HOURS IN <br /> AMANCE POR ALL REOUREO PDNP TIONS AT 1208)t88i 22. COMPJFTE DRAWING AT LOWER AICA NONMED. <br /> BIPmd%�/ ��!/)/✓/L L(� TRIa ��PS Data <br /> ROT"Al ON.1.SSSIN ScHe "t. <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE MQIE - t. LOCATION OF HOUSE SEWAGE 09MBAL SYSTEM OB N10LOSED <br /> 2. OUTLINE OF THE MIUPERTY,GIVNM DIMENSIONS AM MMM DIRECTION. EXPANSION OF SEWAGE M MUM SYSTEMS. <br /> J. DIMENSIONEO OUTLINES ANO LOCATION OF ALL EXISTING AND RiOPUSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED Fff Y R. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AM WAMS. ON THE PROMRTY OR ADJOIMM PROPERTY. <br /> ?ee/yvolJolie..�S { <br /> V) <br />