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" APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 904 EAST"WEBER AVENUE,STOCKTON,CA 95202 Fly <br /> (209)488-3420 <br /> �r ROiLRE tIl1OABLE CEN.M�T_EIIPIREZ l TEARER DAT iaaUEP <br /> sots FR <br /> M AQ"W CO IR/NDE EL MAGE TO TIME SAN JOAOUM COVHIY TOR A f`F,I/+IR TO GO1 HlITRIICT aNhpn�HBTAII TIIE VM'W DEMM"FE',TIIIR AMICATNIN M MAOV!N cOMMIWCF w 11 SAN <br /> JOAn11N COUNIY DEVELOPMENT ilt1T,CiIA/PTEa 9"1 116.7 AHO THE RTANDAPRID or SAN JOAt)taH COt/NTY ry1RLIC IIFALIN OtnV10ES,E#WIRRNMENTAL/KALIII bDnRK,N, <br /> JOS ADnrESRSIA APNP V L f^3 <br /> UN <br /> f�D clrY oC_ICTi,IJ PAIkE4RIZT, . ( 3-OZ'OCa <br />' oweRM"R NAME <br /> COHT <br />{ MCIOR J•//����T� <br /> . AOdOaa Ij i <br /> FOS CONtMACTOR uc, "MN;/ <br /> AbbfEa/ LICI NNINF <br /> TYPE OF VYFttALlMP, ❑New Yvan ❑RfMACFMFNT WELL AIOHITDN1xf welt P ❑Ol11rn ' <br /> 1r❑yy INSTTA--LrI11TroN Q WttL w911M REPAIR ❑Crepe"CONNECT REPAIR ❑VAroa EaTFucTIOu WEtt 1 <br /> LJ Nw.W II�.r.M p, J <br /> 5y-OT p11MN F1E1RH Af1AP SET----YT, FIRST WAT[R IFVEL <br /> r�T O <br /> Vi"OF"pfMVIf.E WELL V OTOMMSICAL WELL/ ❑ son,Moreno <br /> A <br />" ❑nFRrltucTroN: <br /> INls US TYPEO CO iIRUC71ON PEC61CA W <br /> 13INnVRTMlAL ❑OITN ROttbM OF WA <br /> l b1A" ELL ERCAVATKIH DrA"OF CONMWTOr CARAro <br /> ©OOMFSTICff"VATF ❑OMAVFL PACKlWrf. Trpf OF CA9NMMTEEUPVC <br /> ❑PUNIM./MUMCIPAL ❑OR N dA-OF WILL CASINO D <br /> �-y OEP Of OF OMOttf SEAL SITCKICATION <br /> 1J IMOMTOMN An ❑OIINR ORO1Tt REAL WMA <br /> T- Il FURY 4MDU1 RMANO NAME UJ <br /> *M MOMTOINO (TROUT RfAtKRWTO;❑Yw [IN. CONCMErfOF/TALRVnrltFMIfY- UJ*M x <br /> ATYTIDx-OfPtn LO"c"CNFaifn OOXNtow NIT <br /> NIOPOFED COIMTMXrtONAR*eUNd"NOO:MM ROTA1ME <br /> AIR 1R,TAm AVOFa CMLE OTMA <br /> I/NgRY CEMTMY TIIAT I IIAVT PptRAWO THRI AITElCAT1ON Ano TNAT lPM WO/TL WkL BE DONE N ACCORDANCE YM1N SAN JOACKRN CnVWrV OFRIINANCEp.in ATE UWS.ANO MittO Ann <br /> 'JaS r,1roHp OT TME AN JOA WIN CO1xfTY,HOLIF OWNER OR IICENEEe ADE W'/SIONAI VME CFmsME111ME/otjeyVlNO•'1 G[ATRY THAT N 1/R?PFIr OMMATICf eI THE NTN(TOp YR RCII <br /> TIRR RfrMn If MMlEO.l alUtRpIOT[MPLOY I'tRROpMI OIIIIIJLCT TO WeRRMAH'S COMPEIISA TIONtAVM OF CALIFOINM.•COMIRACTOM'E IIIWNO Or SUS{OMAACTMO p1ONAflMF ctrnMMEl <br /> " rOL1eW11M: •r cfwwY T/OAT N TIN PETIFOFYAANCE OF THE VYOMK FOM LVWN TFMa PERMIT Ip NKNO.I SUAL"tW'LOY PfRpONS RIIOJfCT To NNTIIAFAN'p CeMp"aa"O"tAWR of <br /> CAI.NOIaAA.-,111E AFry/CAM)mug? <br /> J(C�AI�JI 24 tRfV111 f11 ADV/A/,1190E TOM ALL RIOU1RfD INRPFC}IOFIf AT 11OEf.M.f.1l.COEtPI MMrINO E,E OAT LOwTr AIIFA N1OV1n[tI, <br /> ' TMa <br /> 1'107 PIJLH R>•Oa.1.brN T•Iq. <br /> 1.NAMEp OF a11ERS OR ROADS NEAREST TO OM MOURnow TIME Pno1Emy, A.LOCATION OF IIDUK RFWAOF DIaw/At ayptfM OR rMrn RFn <br /> Z."I"t"O <br /> b OVfF TTN IfgnfpFy,OIVRIe ONfEnproNa ANb NOMTH b11ECSg11. ExT'ANSIOH OF pEWAOf OTMOSAI WerEMR, <br /> 7.bNAfNaroHEI1NI,■AHO LOCATION OF A!L fxlatRle AHD IR10P0REh p.LOCA110N OT WELL#MRTNN MArIRlp DF ONE RuNDIln(Wry rtO <br /> STFIUCrUDE►.rMWO Iro COVERED A1EAf!►UGM AR PATIO►,MVEWAYR.AND WAULE. ON TIME ProwsitY OR ADJORIIFq"wriftTy. <br /> wELL(ULA; �,fr <br /> -J x <br /> 1r VCE <br /> L-✓.CLL CAC,) <br /> JUL R <br /> ' `�S�aaLJi7N(:.JIJri1t <br /> FNVFRONM@NIAI,NFALrH ry,Mg Tlli . <br /> DfPART?A 1T USE ONLY 7 <br /> AppRenlp..A...p..A aT r �b.•l. —2 0— A... <br /> ^lFAf <br /> O,a,I L.p.etNn AF nn. Mp 0_0_MY - / <br /> O+hl Ellen 1r�R.elf.n RY / <br /> 0.1. <br /> G-.: ST 5t-- ?f4r^E <br /> ACCOUNTIMO ONLY, MOI FAC/ <br /> PE COOEI FEE INFO AMOLWY RFNRTTM INCRE AEN atc"D RY DATE "WAy ISptyICt"Eau"F NUMBER n1VNCf <br /> `+aeRh Sarv."Envlrb,173(1/97) <br /> 1 <br />