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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES (`�1 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,0< BOX 3881 9 M EAST WEBER AVENUE:, STOCKTON, CA gMf X88 <br /> 1209) 468-3420 <br /> NORAFFUNDA_ 1.1 PERMIT EXPIRES I YEAR FROM DA71 ISSUED <br /> ICImpIBtB IR TI1911cSt11 <br /> APrVCATK:N IS HERE BY MAGE TO THE SAN JOAOWN COUIN-Y FOn A PERMIT TO rONSTRUrT ANmen INSTALL THE WORK DESCRIBED.TINS MTLK;ATIOH 19 MADE IN COMF".IAWf:E WRII SAN <br /> JOAOUIN COUNTY DEVELOPMENT <br /> /TITLEE,,C14AFITER 9-1115.3 AND Vitt STANOAROR OF RAN JOAOUIN COUNTYryPU-RI.IC HEALTII BERVlCES,FwAPONMENTAL HEALTH OIV1WN. <br /> JOB AOORESSM01 APNO ( Z—Tr-` (']C 111466-e R0 r;IT-f � L TQ/{I7 PARCEL R12ElAFT1/__ ) J, <br /> OWWn'B NAME-C-1 KGG ICE(�,c�`,t'=�y� jwE AIxMERR S/4-OVIe p`S"Gr.� (�iPFaNE I [ T z0�.► <br /> CONTRACTORRJ , � p(,(•OIL C� _ADURE9S�•��Q d Qr��IIC,(�5iT41ONE t�/l <br /> RUR CONIRACI(M tr----rt A.UDDF99 ��•� ` HCI 1.110 NEr <br /> TY11F OF WELMMr- u NEN•WELL ❑ TIFPEACFMFNI WFIL ❑ MONTTOnING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑VITLL 9YSIEM REPAIR IJ C1109S-CONNECT REPAIR ❑ VAPOR EKTRAC110N WELL r J <br /> Su� ❑N«. N`e'1 N.P-_ /74/ DEPTH MJMP$F7 FT. RRRT WATER IEVEL��y <br /> (FYPF OF PTIMPI <br /> f� 944-/a' � E,At D om-or SEnvIcE WELL I] OFOr11YSICAt WELL I ❑ Sam BORNO R <br /> ❑DF9TnOCTIDN;'r^ / //(( I7t7 <br /> INTENDED l IYVLOF WELL -79N{rRUCTION.1PEC91CATIONS <br /> ❑ZMAL 11 OMM SO rTOM INA.OF WELL EKCAVA1ION DIA.CF CONDUCTOR CARING r) <br /> r{rl9TICMMVATE F��T!nMVEL PACKJ912E _ TYPE OF CARINOrRTFFIJPVC DIA.OF WEIL CA91ND fy <br /> ❑ P MUCIMIINICIPAL Q DnIVFN OEM It OF OROIJI"SF.AL - _ S,4CIFICATKIN -_ —— A <br /> ❑ IRRIOATIONJAO ❑OTHER G11011T SEAL INNTAf LIED By GRO1rT BRM <br /> AND NAE_ F <br /> 11 MONITORING ORIOUT SEAL PUMrwni [ry.J Y. ❑No CONCRETE PEOFRIAL BY OF%I I FR•❑Y.. ❑'m •, <br /> APPROX.CW"H LOCKRM CHFITTFI1 BOXISIOVF.PIPE` 5 <br /> PROPOSED CONSTRLICTTONIDTrLUNO METHOD: MID 110TARY_ AIR ROTARY AUDfFt CAMP OIHFR <br /> 1 IKVENY CERTIFY THAT I HAVE PREPAREn THIR A14-LIC ATKIN AND THAT IIIF 1MITR(Wh 1-BE DONE IN ACCORDANCE WITH RAH JOAOL9N COUMY OIIIMANCEB,WTATE LAWS,ANO Rtll E8 ANn <br /> MOULATIONS OF THE BAN JOAOUIN rOVNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLC-WONO:•1 CERTIFY THAT IN THE PfW0nMANCE Or TILE WOFK roll VAIIg1 � <br /> THIS PERMIT 19 I9RUED,I 911AU 1.NOT EMPLOY PFR910NR RVRJFCT TO WORKMAN'S COMMW$ATTON LAWN OF CALR'OFVJIA.' CGITTRACTOR'S HRSHO OR fFIJII-CONT RACTIMO WNATLIFIE CERTIFIER e` <br /> THF FOIIOWINO! 'I CERTIFY THAT IN THE ffnFOROAAFR:F Or THE WOIw rON WHIN THIS PERMrr 1R IBBVEO,1114ALL EMPLOY PERSONS SUBJECT TO WORKArAN'■COMPEl/BATION IAWN OF jV <br /> CAI IrORMA.' AMUC ANT MUST CALL 24 HO-WO Of ADVANCE FOR ALL REOURED LMB NS 12001 N' 2!. COMPLETE DRANANO AT LOWER ARIEA f'"OV1190. <br /> B1pr.M X T11I. <br /> 0.1.�^ <br /> rLOT PUN ID.w to 9o.N.•1 90.1. 'to <br /> 1. NAEAFB OF BTMFETR OR ROADS NEARFRT TO 011 ROUNOMO THE PnOPEnrv, 4. LOCATION OF"OLW-9EVNAGE DISPOSAL SY6TFM On MYJPOBED <br /> 2. OUTLINE OF TIRE PTIOPERTY,(""No DIMENWN8 AND NORTH DIIIECTION. EXPANRION OF SFWAOE DISPOSAL BYTTTEMR. <br /> J. DIMF.FIBIONED OUTLINES MAT IOCATION OF ALL f URT?NG AND PT Potfo S. LOCATION OF WELLS NTTHIN RIAORJB OF ONE NI)Nr"wn FI Fry FT <br /> STRUCIURE9,INCLUDING COVERED AREAS[OUCH AS PATIOS,DRIVEWAYS,ANO WALKS. ON THE PROPERTY OR ADJOINING Pf1OPEMY. <br /> . ... .. .................... ..:......... ...< <br /> ICS `r ' <br /> ....... ..... ....4 <br /> , <br /> t LJ. .V lYlr iti�l^.•..;.•. <br /> DEPARTMENT V99 ONLY <br /> koN..tlen Ae..pi<.1 BY - v S Z A.r Z�_r f <br /> G,.ul I...Pne,l.t.BY D./. rump O—omtt-n RY _D.1.�•30 91. <br /> 1�.1n.etbn InP•otl.,,.Nr__ '- -._ D.t. <br /> ACCOLM IINO ONLY: ^y AIDr fACf <br /> PE COOE[< FEE INFO AMOUNT REMIIIFD IEC ICASH RECI3VED BY DATE P11WITISERVICE 1ACILITIT NUNB61 INVOICE <br /> "SO/T <br /> y Q ir' 10 AdL3a(, <br /> Pub.Heellh Serv.-EnVlro. 173(3/96) <br />