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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O,BOX 388,304 EAST WEBER AVME,STOCKTOR CA 95201388 <br /> (205)488.3420 <br /> NOWNEFBNDRlLE PENNIT EXPIRES 1 YEAR FUDR_ DATE ISSUED <br /> Me"IEu i1 TT+Aaul <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT ANDAR INSTALL THE WWW DE!SCIEBED.THIS APPLICATION N MADE N CCAAPLIANCE WRN BAN <br /> JOAOUIN COUPRY DEVELOPMENT TIRE,CHAPTER 8-1115.7 AND THE STANOAROS OF SAN JOAQUN COUNTY PUBLIC HEALTH SMACE9,ENVIRO AMI TIAL HMTH DIVISION. <br /> JOB ADOFESBIOR.AIMS '/hM 41 J&DIM, Ga ME -An Cm ST�!LTD4) PARCEL 99MAPWO <br /> OwfERS NANISJ4)1'yl0M L Q. 00116 n MI <br /> ICNE-14141- AooREa ��4Ii + 9S2016,y <br /> ��T-13YL•S•fin-LL� W AVOESS E M�A�(J/L1CI ,��PHONE,- � <br /> BUB CONTRACTOR ADDRESS PHONE <br /> TYPE OF WEUIPUW ❑NEW WELL ❑REPLACEMENT WELL ❑MoMTORBq WELL/ ❑OTTER_ <br /> j ❑*.wrAuuATxm ❑wtLL or etE-EA,RErjum ❑CMOs CONNECT Wpm" 13POW <br /> VAR ERrAACT1ON ELL• ,/ <br /> �UBmR"l A�❑Ww L7 M,.� N.I. .�/C..L, OEPTH PLUMP BET�FT. FMIST WATTJI RML Lz� O <br /> ❑Dom—I smnTY E WELL ❑two" AL v 0 ❑ BOLL OOHING IF <br /> ❑DESTFIUCTM7 <br /> o <br /> MuffmLm Type Of WPA CON4TAUCTION SPEOMATIONG A rJ <br /> ❑7/MgYf71EAL ❑OPEN BOTTOM DIA.Of WELL OCCAVATICN TAA.OF CONDUCTOR CAMPOS D <br /> WDOMESTICNIEVATE 13 GRAVEL PACKAOM_ TYPE Of CANNO/BTEEI/PLS DU.OF WELL CABBNE D <br /> ❑RISUC^#UNIGPAL 13IE <br /> DVEN DEPTH OF OIK/UT SEAL _ SPECIFICATION A <br /> ❑NISGATICOUAG ❑OTHETI GROUT MEAL INSTALLED BY _ GROUT RANO NAME E <br /> ❑MOwTORNG GAOUT MEAL P111.1PE0:❑Y- ❑N. CONCRETE PEDESTAL VY DRK.LER❑Y- ❑N. a F <br /> A►FROK.DYTNLocuom CIESTQI BOX/STOVE PIPE- S <br /> "ROPOEm CONTFUCTKH4dWUN0-0: MUO BOTANY AEI ROTARY AUGEN CABLE OTHER <br /> I IIE9EEY CERFIFY THAT I HAVE PIIEPAREO THIS APPLICATION ANO TUT THE WORK WALL ME OONE N ACCORDANCE WITH SAH JOAOLIIN COUNrY opamANCES.STATE LAYVS.AND PULES AND <br /> REOULATIONS OF THE MAN JOAOUN COUNTY.HOMESE <br /> OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FIDLIDWNG;R CERTIFY THAT N THE PE7/ N/ <br /> OISJCE LE OF TWORK FOR WMCIp. <br /> THIS PEANUT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO W WWAAN'S COMPENSATION LAWS Of CAUFORILA.'CONTRACTONY MNNO ON SUSLOMMCTm SISNATUNE CERTSIEM <br /> THE FOLLOWING: '1 CERTIFY THAT N THE PE/EOfWANCE OF THE WORK FOR WHICH THIS PERMfT 1M ISSUED,?SHALL EMPLOY PERSONS WBJECT TO WOPBWAN'S CONB@ISADON LAWS OF <br /> CIWFOINAPPLICANT MUMT CALL 24 HOURS N All"AheS POR ILLI,N[OIIINED RL TM1a I,7 1r1S11 MS-,wm,, CoMRETE ORAW NG AT LOWER AREA P110VIOED, p <br /> n.,..x �\/\cr7d2, T,II._ <br /> PLOT RAN WL 1.S..I.II <br /> 1. NAMES of SFR ETS OR ROADS NEAREST TO OR SING OUNDTHE PMOPEWY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM ON PPDPDMm <br /> Z.OUTLINE OF THE PROPERTY,GIVING OlUENSIONO AND NORTH DIRECTION. EXPANSION Of SEWAGE DISPOSAL SYSTEMS. <br /> 7,DIMENSIONED OUTLINES AND LOCATION OF ALL ExISTINO AND PROPOSED S.L.00.ATICH OF WELLS WITHIN NADIUS OF ONE HUNDRED FIFTY FT.' <br /> STRICTUPEM,NCLU RM COVERED AREAS MUCH AB PATIOS,DRIVEWAYS.AM WALKS. ON THE PROPERTY OR ADJORBN 1 RK)PFRTY. <br /> ... i (......:....:. . . .. .. <br /> • L , <br /> gpL,Lf <br /> :.... .... :. :. ...:... ... . .. _ p ;�... <br /> ....... <br /> .,...... e. . ... : ..... <br /> H'i J4+LJLIf <br /> ......;... P <br /> ....:.. ..: <br /> • Ubi€IC•HEAL1`-H SERVICES ' <br /> .N.VIHUN;LnEis 10,% <br /> DEPARTMENT USE ONLY <br /> ANNbMMn A—pled By__ D.I. _A. `/J�l/•/ice{ <br /> eraA M.0.a B7_ D.1 wA In.P..d.11 BT <br /> Owl—l.n k.p..tbn BY 0.i. <br /> C.mm ; <br /> ACC O'AfTINO ONLY; AAI FAC/ <br /> Ma'CODSI FH INFO AMOUNT fwmrr PD IIBC A:AMN RSCIEVED BY DATE PEISNRANErACE RROUKAT NUNISSII INVOICS <br /> 0$2g <br />