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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-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEfcomD <br /> AMICAIION OR HERE BY MADE TO THE CAN JOAWIN COUNTY FOR A PERMIT TO CONSTIRUCleff I <br /> CONSTRUCT INSTALL THE WGNE DESCnDUG.TIPS AMICATION IS MADE IN COMRIANCF WIT It PAN <br /> "AMIN COUNTY DEVELOPMENT TALE,CHAPFEn 9-1119.3 AND THE STANDARDS OF RAN JOAOUHN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDREssion AI <br /> CITY s ff // PARCEL.SIZE/PINIInvuFn <br /> COPUR CNAME Hu. •IlfwJrp/ � AIONF.I_�O/ted)S� <br /> AADPESP <br /> CONIMCTOD E d ADUGERB e--.00/OZ �%'�•A�lIC1 <br /> PIIS CONTMCTOn MGM E_! f'Z79 <br /> ADORESR 1101 <br /> ATONE I <br /> PE OF WELUPUMP• ElNEW W11W <br /> ELL ❑ se"CEMEW WELL MONITORING ELL I ❑ OTHER - — <br /> TY ❑ INaTALLATHH, ❑ WELL SYSTEM DEPART ❑ CMIM CONNECT IMPAIn ❑ VAPOR EKTH&C110N WELL I <br /> Nndr ILP. DEPTH RUMP BET FU, fUAT WATER LEVEL _ <br /> DYPE 01 MMPI _— O <br /> ///J/////� ❑ O -0E-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL SOnINO <br /> 1� —VLIJS <br /> I14=dcd 13) <br /> �IFH EO U E TYPE OF WE <br /> ❑ IN PIAL ❑OrENBOrTOM <br /> DIA.OF WELL EXCAVATION <br /> MEATICVIA.OF CONDUCTOR CASINO <br /> Ib /AIIVATE GRAVEL PACK/SAE O <br /> TYPE OF CAPINOISTFEIANC VIA.OF WELL CASINO <br /> ❑ ANGATIONIAGPgt mw" DEPTH OF GROW SEAL O - <br /> ❑ PRNMTION/IOD OTHER Sf4CIFICR1pN R <br /> ❑ <br /> OMUT SEAL INSTALLED BY BMW BRAND NAME <br /> APPROX DEPTMHH MONS GRDUT SEAL MMKF: ❑Yr ON. CONCRETE IEM"S U)BYDP .Ely. [IN. S <br /> LOCKING CHESTER BOIUSTOVE PIPE <br /> IgOPONFD COMNTIIIK%HONn1NllMG METHOD; MUD RDTAmS <br /> AIB RDTAm AUGER CARIE OTHER <br /> i IIEREBV CEnfIFV THAI I HAVE N1EPA11ED i i ATRICATION ANO TIIQ THE WON(V 15 BE DONE DM ACCORDANCE WIiN SAN JOAOUN COVWY ORDINANCES,STATE UWR.AN <br /> REGULATIONS OF TIM BAN"AWIN COUNTY. HOME OW Wn OR LICENSED AGENT'S SIGNATURE CEDUNIES THE FOLLOW WOI-1 CEIAIFV THAT IN THE PEpfOnM O G.AND <br /> TATA"MOTOR INRUFD,1 MAIL NOT EMPLOY PEPRONS SUBJECT TO WORKMAN'S COMPENSATION""OF CALIFORNIA.• COMMCTOR'S IANNB OR NS- PNCE OF TIIE WON(FOOD WIIICII <br /> THE fO1LOWINO� 1PCPEynfIFY THAT IN TIIE PERIORMAHf,E OF THE NqP(FOR W111CN TMB PE11MA IR IBSUFb,1 SHALL EMA.OY PEnSONe IGSIACT TO WORKMAN ll COMPMIIAUHON"WeorCALROnNIA.• TINA CA T �A q�UAOVAMCF FOR ALL RFOUREO IMF�OM I.yS` .r,.�EyR,,1OOWER�,REA � <br /> PIOru.1 K K!��t C R CO_A/;/yy <br /> ROT PLAN ON.le M.I.I Ik.In •ro <br /> 1. NAMER OF RTDFETN On ROADS NEAREST TO On SOUNDING THE MOTERTY. <br /> S. (HAWS OF TIN AbPEnry,n1Ulb DIMENSIONS AND HOW"DIRECTION. A. LOCATION OF HOUSE SMAOE DISPOSAL SYSTEM On vmoml EO <br /> P. OIMMRIONED OUTLINES AND LOCATION OF ALL EXISTING AND PbrOSEb EXPANSION OF SEWADE DISPOSAL eYNIFM6. <br /> PTSUCTUBER,INCLUDING COVERED AREAS SUCH As PATIOS,UNVEWAYR,AND WALKS, S. LOCATION OF WELLS WAIAN BAGO/e OF ONE HUNOPED Priv rl. <br /> ON THE momerrY On ADJOINmr,roommY. <br /> tJ <br /> © c y!� <br /> PAYMENT <br /> FEB <br /> 31996 <br /> i N <br /> ?.. SAM1J "%OU114COIJNiV <br /> 'PuskiENUIRONh1FNTA�L1 NEATpt!r(❑WIFg <br /> EN f MSI[) 1 1i <br /> DEPARTMMT USE ONLY <br /> Annne.11mr Aee.plM Py <br /> Dole <br /> I <br /> SIAM { <br /> m...I,,.n.en..,nr .1. PIInP In.mm�en ey �. •�O•,Q'es <br /> U'wlnnnen In.n.flMn By <br /> ba• <br /> ACCOUMONO ONLY, ARM FACT <br /> PE CODES FEE IMO AMOUNT REMITTED CHECK /CASH RECEIVED By DATE PEIIRWINERVICE REGUENT NVNMM INVOICE <br /> Pub.Health Sere.-Enviro.173(1/97) - - -- <br />