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E_ <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201358 <br /> ISS, (209)4683420 <br /> NON REFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED <br /> ICa"WM 1.TTIpIIuWI <br /> APPLICATION IS HERE BY MADE TO THE SAH JOAWIN COUNTY FOR A WHEAT TO CONSTRUCT AMNON INSTALL THE WORE DESCRIBED.THIS APftICATWN 16 MADE IN COMPLIANCE WITH SAH <br /> LONDON COUNTY DEVELDPMENT TITLE,CHAPTEfl9�I 115,JANO THE ANDAMS OF BAN JOAOUIN COUNTY PVOUCH TH SEAVICES,ENVIRONMENTAL HEALTH DIVISON. <br /> R/ <br /> JOB AOOPE88MP AFH/�� /�� /I T f ✓ PA CT' �� ./ PARCEL SQEIAR:f <br /> OWNER'e NAMEAWN# <br /> ADDRESS iES0./(,M. P E� <br /> COWMCTOF�Y V L A /IA G -'� I_/I c. AOpDE..2 /'^ /Le Jc�_��!iJ e4N L'Cf�7 C� PHONE/�Y� V <br /> r SUB CONTMCTOP MORf56 UCE PHONE IF <br /> TYPE OF WELNLCAN ❑NEW WELL ❑MPLACEMENT WELL ❑MONITONNG WELL I ❑OTHER <br /> ❑INSTAAILATION ❑ NE <br /> WELL SSETEM P1.. ❑G..S{ONCT REPMR ❑IAM.EX1PAC11CF.I1I J <br /> ElHAW MANAH, H.P. A.SUMP SET�j f. FRUIT WATf.LEVEL) <br /> AER, TYPE OF%IM% <br /> ❑OUTaF.SEAYIa wEu ❑OEOPHYS,CAL WELL. ❑ apa MwxD B - <br /> ❑Df6TMCTIOH' <br /> MOEO VeE <br /> TYPE.1 WELL PKAT... A <br /> ❑FWUNNGAAL El M.BOTTOM NA.OF WELL EXCAVATION DIA.Of CONDUCTOR CASING O <br /> ` ;9 COMESIIC/PNVATE ❑OMVEL BACKLASH TYPE OF CASINGISTEELRVC CIA Of Will CA8W0 O <br /> ❑RIBUCIMUNICIFK ❑DRIVER DEPTH OF SMUT SEAL SPECIFICATMM A <br /> ADEN'... ❑OTHER DM.T SEAL RDTALLM BY SMUT SNND NAME E <br /> ❑MOwrpwM E GMUT SEAL wMPEO:❑1 0 A CONCRFTEPEOfeTALBVOwuFR:0WA ON, X ] <br /> ` APP OX.DEPTH I^ LOCNIHB CHESTER MXISTOVE%FX8 r <br /> PMABSS CONITAWTONIMBWNO METHOD: MUD MTAAY AIR PATTARI AWE. CABLE OTHER I1f <br /> I HEREBY CUTIMTHAT I HAVE MANAGES THIS APPUCATWN AND THAT THE NOIR WILL BE DONE IN ACCORDANCE WITH SAN JOAWINCOUNTY O.WNANCES.STATE LAWS,AND RULES AND ` <br /> REGULATIONS OF THE SAN I...COUNTY.MME OWNER O.LICENSED AGENT'S SIGNATURE CENTERS THE FOLLOWING:-1 CONTEST THAT IN THE PF.FONAAKE Of THE WORL FORNTICH <br /> THIS RESULT N ISSUED.6 SHALL HOT EMPLOWMAWNS SUBJECT TO WONXMAN'B COMPENSATION LAWS OFCAWOR,IA.'COWMCTOR'6H,NMORe DB QNTMCTWGBWNAfUMCEWIfNS <br /> ` THE FOLLOWMD: -I CERTIFY THAT M THE PERFOW.1 10174, <br /> OFTHE WOR(fOfl WIIIGH THIB,fRMR IS ISSUED.I SHALL EMPLOY PERSON$SUBJECT TO WORNMAN'S COMIENi.E} IAW80F <br /> ZCAllF01Wl PIICAW MYSTIC BE NG ,M ADV/ANC.FOR ZI.EOMREO IRBP�TR/TQHB��lRl,�i 11O111BBiEie.COMPLETE DMWINO AT LOWER AREA PROVIDED <br /> w �� CG THE Y� E�E—N Dx. IY N <br /> LILOTAW THE PROPW,SBMEI SWP� _ <br /> 1.CRINES Of eTHEEPR OR MADE NEAREST TO AND NOR THE PROPERTY. 1, LO ANN N OP SEWAECLAWGE <br /> EEREFU AL SYSTEMS.BS. OR RIOMS[O <br /> ` 3.OVTIINE OF THE PROPERTY.6,VIM gMEN40N6 AND CORTIN OWf<TW N. fXPAN610N OF SEWAGE pSPoBAL BYBLENB. <br /> AGE N...ED OUTLINES AND LOCATION OF ALL EXISTING AND PMPoIkOE S OF WELLS WITHIN MgU6 OF ONE HUMPED FIFTY FT.STRUCTUREB.INCLUDING COVERED AREAS SUCH AS PATIOS.DNVEWAYS,AND WADES. ON THE PROPERTY CR ADJOINING PROPERTY. <br /> ARRE <br /> Z 1 <br /> RESS <br /> BERE <br /> I <br /> n( rC.LtiI/J �✓c C✓.sC <br /> ISSIS . G <br /> r% a S <br /> SEP 1 3 1995 <br /> r <br /> BEEN DEPANTMENT USE DNfv 1'L IIINP L + �' CERVI c <br /> AF. AuARIG A SHE L T9L FARE <br /> Ga ImowIw By Pump lm NNAN.ITVISA -, <br /> INS`, D-mmem IINF—A,BY CA <br /> DNnnD OHLr: ARM 1-1 <br /> WB <br /> Pf ceDG <br /> � 5 I.F. AMOUNT <br /> s (•.�=1.'�,oC i'7s� <.: tcto,� �1%islt —G7IMU'LET` o�a973 <br /> V <br />