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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)488-3420 <br /> NOR-AfUROAUtE pywiT PfA(J 1 YEAR fROA1 d iE MUD <br /> ILe1EpM1.In iT$A.E1.) <br /> APPLICATION 19 PERE W MAGE TO THE BAN JOAQUIN COUNTY FOR A PEWAA TO CONITRLICT ANOPOA INSTALL THE WOPS(DE/CfieED.TIM!APFkICAtIOH 14 MADE IN COMPLIANCE WAIT SAN <br /> AOAOUG/CCU%rrY,"ELtLOPMENT TITLE.CHAPTER 9 1115.ZA,('Q,Lty(!T A F M COUNTY-M1C IEAIiN SERVICES,fNVGONASEIOTAL HEALTH D:NSgN. <br /> /J5 -/o- iii o1l[d.11/J]cylljJl � � / •r <br /> JOI R'l MAW APT I.' � Ctry LF Azg�j PARCEL IIEMJAPNI <br /> D«+fn'/NAME__- ? J [711�W� DEQO .00nEet%EtZy�! C`. AWY 26 vaNf t�Za9 �3i—!75'/ <br /> cath RACTOR z t.,EJ/�E..t_/T-Icy <br /> ADCNEe! IbzS'9 E,/lk/Y z6 UCA —INOfE/Cz-7931- 7si <br /> Blle CONTRACTON ADCf✓ZSS UCA ROME A <br /> tYMOF VWU,?VUF-. NEWWttl ❑Pf—L CMMENT WELL ❑MONRONNO VAu1L�Jy OTIER <br /> ❑MSTALLAT*N ElSY <br /> WELL STEM REPAIR CROSS-CONNECT RPAW LJ VAPOR EX.,RACTNIN WEU f J <br /> ❑N—El R...A H.P. OMPTH PUMP SLT T. FWIT WATER LEM D <br /> RYPEW PVMPT �— <br /> ❑OFffdf SEnV ct"LL ❑GF0FITYEICAt P.EU A ❑ sOIL BOWNO g <br /> ❑OteT WICTION• <br /> I.RARD to Iii rY OF wEEL COMI RIACTtOx IPfCOHCA TOMS A <br /> ❑OOKIETRIAt ❑OPEN IOTfOM bIA.Of WELL EXCAVATION LMA.Of CONDUCTOR CAST HO O <br /> ❑DO AHE..ICAM.VATf ❑ORAIML PACK/EITt_ TVPE OF CAS—NTETLMP DIA.Of WELL CAMNO p <br /> ❑VOSMIMONICWAL 0 MVEN OEPIM OF ORDVT SEAL _ "CIACAT1oN R <br /> ❑IRNOATMNIAO ❑OTHER CROW/FAL INSTALIED SY OROUT IMNO NAME E <br /> ❑A*,,Hrom-O (I—W SEAL-HIED:❑Yr ❑H. CONCRTFMOESTM.RYOfALM[3Yr CIN. s <br /> A—X'am" —Y LOCXMO CfE"t,,IOI{ISTOVt"w S <br /> -a-.®COM.TTIUCTIONlD..lUNO METHOD:MVO NOTARY AIR POTARY AUGER CABLE OT1Ei�� <br /> 1 <br /> I Nf@IV CERTIFY THAT I IIAVf PREPARED TMS AfS1iCATpN ANO THAT HE WOI'K WILL bE GONE N ACCOROAlI_'F W'ITN SAM JOAOUM COIMTY OFEMIAMCEI,OTATE LAWS,AND M1UI,EE AND <br /> REOULATIONI OF THE EAN JOAOOM COVHTY.HOME OWNER 0R LICYNBEO AOFW'S SIONATURM CMRTREe THE f UOW !'I CERTIFY THAT BI THE PEMOMANCE OF TME WOR(FOR 1S A C']j <br /> TMI PENAA ISISSUED,I WALL NOT EMPLOY PERSONS eV A"TO wORtMAN'/CC"PD4$ATMN tAW%OF CA.MD~A-'CONTNACIOR'E NWtHO OR EL/{�OMgACTNO/gNATlJfE CERTIFIEI T <br /> 1HE fOLLOHMNO: '1 CFRTIFY T NAT M TNM PENFoRMAWE OF THE WORK FOA V—CH THIS PERA/TT 7S ISOM&.I[NALL EMPLOY M%SDMS IFIZACT TO wORt11FAN'S COMP"SAY—LAWS OF <br /> CALFORIIA-' TK ARIICAITT ATt/ST CALL I-I HOW M ADVANCt FONT ALL IIITNAIHED M.IECTNIM■AT fY.t.l Ap JA lI,COMPLFTE OPAWMO AT LOWER AAA PMOVN". Q <br /> Sl/n�t X TK, OM. _ <br /> May PLAN ODI.-1.6e1.1 <br /> I. NAAAMI OF STREETS OR PADS NFARNT TO OR tOLff OIN0 THE PftlItTOY. 1.LOCATION OF HOUSE SEWAGE DISpo#AL EYnEM OR Ph_,,ED <br /> E.OUTt Nf OF THE PROPERTY.OPAN G DAIENeIONS ANIO NORTH VI EC,I H, EXPANSMN OF IIEWAOM bOSPOIAL SYSTEMS. <br /> 1.DMEN*q D OWtRa`S AND LOCATON Of ALL tXISTRIO AHO PHOfOSfO t,LOCA7WAI OF VITUS WFASNI RAMS OF ONE HFJNLtED FETY F,. <br /> ITRUCTLIRI,NCLt"46 COVERED AREAS SUCH AS PATIOS,DRIVEWAY(,AND WALXe. ON THE ITOPLRTYOR AOJOIHMNT PROPERTY. Cl <br /> vi " A-LP-evy <br /> �Fou v lu <br /> off( m m pla~NT <br /> RECE IED <br /> 1 1- s.vr.l;�noa�wccuKry <br /> PU 'C HEALTH SERVICES <br /> +�33• 11J G tNVIRONMENTAl Nr-,LTH OfOSION <br /> JI <br /> /JL OFFMTMEMT Vf[ONLY <br /> Aspin«b..Aee.l,l.d <br /> my_ llllll//{Ty,/nL^iYt,1, nom(/ b N hn a r <br /> Cann.�rt: <br /> AC COI;MTRa ONLY: ATO[ FACE <br /> f-y COOS. F(�EEINfo AMOUNT NOJ.TTTD NECK M:A.N McEm"ST DAtf P9"TISEAVKl REOUEET NLMNER INVOICE <br /> aaoy go __-- <br /> Pub�oe ti Sam.-Emiro.173(1197) <br />