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APPLICATION FOR WELLJPUMP 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 /> NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICIMPMtI IS TToBIItal <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAORN COUNTY FON A PERMIT TO CONSTNUCT ANOMR INSTALL THE WORK DESCRSED.THIS APPLICATION IE MADE N COMPLIANCE WRIT SAN <br /> JOAOVN COUNTY DfVELOPMENT TM-L CHAPTER 9-1116.3,,�q pTN RANO�L��p//�S SAN JOAC CO PUBLIC HEALTH SERVICES,EM PRONMENTAL HEALTH DIVISION. `I' <br /> JOS ADOWSMA APR# 42_3 pZ. '��.p 4L✓ ( Ft CRY I, PARCEL SIZEIAPN/ ZO ACQ�C <br /> OWNERTB NAME r LG ►�.c V� ADDRESS 2�23DR -1// PHONENE tf -•• ,�/�� L <br /> CONTRACTOR LS r IK ADI...,//? LICIW AfI/6LZ PHONE ryJu�J z \ <br /> SUS CONTRACTOR ADDRESS LICE PHONE <br /> TYPE of wELIJPLMf•. +Ew WELL ❑WMACnAELR WELL ❑MoMToRINo WELL E ❑OTHER <br /> ❑ <br /> INSTALLATION ❑WELL SYSTEM REPAIR ❑CRDeFCONNECT REPASS ❑VAPOR!%TRACTION WELL F J <br /> ❑N..+❑P_W N.P. OEM"PUMP BET—FT. FIRST WATER LEVEL O � <br /> rtrPE of rtiMPl <br /> ❑OUT-OF-SERVICE WELL ❑OEOPHYSK AL WELL E ❑ SON BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TT W CONSTRUCTION SPSCENCATIONI A <br /> !� <br /> 11 INDUSTRIAL C3 <br /> OPEN BOTTOM dA.OF WELL EXCAVATION OU.OF CONDUCTOR CASING O <br /> T <br /> VQOMESTICIRIVATE WRAVEL PACIK/SIZE TYPE OF CASINGMTFEIA DIA.OF WELL CASNO 0 <br /> ❑PUSUCA U WAL ❑DRIVEN DERV OF GROUT REAL SPECIFICATION R , <br /> UwOATIOMAO ❑OTHER GROUT WAL INSTALLED BY Ingst77tT OPOVT IRAND NAME E <br /> ❑MOMro1IN0 �•i,��{n/�� GROUT SEAL PLIMPEO: ❑N. CONCRETE PEDESTAL■ DINRLM❑Y-�N. S <br /> APPROX.OWTH ..! G-t/ ' L00UHG CHESTER BOX/STOVE APF 5 <br /> PRROPOSTD CONITRUCTION/NILUNG METHOD:MUD ROTARY_AIR PIOTAIY AUGER CANE OTHER <br /> I REIBY CERTSFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WOIIL WRL BE DONE N ACCORDANCE WITH SAN MAGIAN COUNTY ORDNANCE$.STATE LAWS.AND RULER AND <br /> 11EOLRATNIHB OF THE IAN JOAGIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWNG:'1 Cf RT Y THAT M THE PE/IFOIMANCE Of THE WORK FOR NAIKH <br /> THIS PNMR IS RSMUEO.I SHALL NOT EMROY PERSON SUBJECT TO WORKMAN'S COMPONAT/ON LAWS OF CALIFORNIA.'CONTRACTON'I HI WNO OR SUE-CONTRIA <br /> ACTWO SIGNATURE CERTFB <br /> THE FOLLOWNM: '1 CERTIFY THAT N THE PERFORMANCE Of THE VMM POR WHICH THIS PEISAR IS ISSUED,1 SHALL EMPLOY PERSONS BUGACT TO WOMMAWS COMPENSATION LAWS OF <br /> CMIFOMMA�'/r,IF APPLICANT MUST <br /> �CA//LLJ- NOW N ADVANCE PGI ALL MOUNIED S►B"O/NS�jAT ISMO 400-1'1227.COMNETE f1MVMNO AT LOWER AREA PROVIDED. <br /> 94.w X V t c.+ I I LL=/AWWo TIN. IT <br /> PLOT PLAN 0—1.S..W <br /> 1.NAMES OF ITMSTS OR ROADS NEAREST TO OR IOUNDIFM THE PROPERTY. 4.LOCATION OF NOUS!SEWAGE OISPOM SYSTEM OR PROPOSED <br /> i.OUTLINE OF THE PROPERTY.ONNIo DIMENSIONS AND NORTH OVECTON. FXPANMOM OF SEWAGE DISPOSAL MTEMO. <br /> ].dMINIPONED OUTNES AND LOCATION OF ALL EXMTINO ARM PIIDPO070 S.LOCATION Of WFLLB WTIIN RADKM OF ONE HUROED FIFTY FT. <br /> STRUCTVKS,NCLUOING COVERED AREAS MUCH AS PATIOS,DRIVEWAYS,AND WAU(S. ON THE PROPERTY OR ADJONIHG PEIDPEATY. <br /> .. .. <br /> p� <br /> y 1�0 PAYMENT �. <br /> F RECEIVED <br /> 6MAY -7 <br /> dOAO TIN COUNTY I <br /> DNISION <br /> 0E1'MTMBIT USE ONLY <br /> APEII.NIsn A..gl.d SY D.1. ���✓ � Mr <br /> o..,,I 10.rs11r„er `fir <br /> 0-1-1 n YI vk.10. Dn. <br /> C.�.... s - - o-Rbu - E V ne R I C�Me� <br /> ACCOUNTNo GILT: AX)/ FAC! <br /> OR COD" FEE INTO AMOUNT REMITTED CIIEC /CA/N RIC BVED SY DATE POWAT/SERVICE MERIT NUMBER INVOICE <br /> -6031 116 5 9g O 15,5 5a <br /> Pub Heehh Serv.-Ewro.173(1/97) <br />