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9-30-1996 12:08PM FROM P' 2 <br /> APPLICATION FOR WEWPUMP PERM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SFRXICIS <br /> ENVIRONMENTAL HEALTH 01YISIOrt� s't :^!' '"i (. NEQLTIi <br /> P.O. BOX 38$ 304 EAST WEBER AVENUE. STOCKTIOR CA 95201.9 <br /> (209) 468.3420 <br /> -3 AM 9• ,j <br /> NON-REFUNDABLE PERMIT ERPIRES 1 YEAR FROM DATE ISSUM <br /> APPLKATIOH m HERE BY MAD(Tb THE SAN JOAGUW COUNTY FOR A PSTLIT TO CONSTNJCT ANOAIR NISTALL THE W01R DE VO.THIS APPLICATION IS WADE IN COMPLIANCE WITH e <br /> JOAOUIN COUNTY DEVRDPMET TITLE.CHAPTER 9-1115.3 ANO THE STANDARDS OF BAN JOAQUN COUNTY PUBLIC NEALTN SERVICED.EHVIRONIAENTAL HEALTH OMBON. <br /> JOBAOOMSS: APP/ U/e<TClleber F /fo rTN_ Lrn A...l✓, ST. _ crtY SlcrkTv-, PAxt0.3ImAPNP �7•ZS-/7�KJ <br /> OVNER'S NAME STT,-47o R2, ve6L,2Li7 a ,'k ADOREBB �%�/7� YLs- '0'/ SA5z&-fmo-e 2o9-93J-X9eJf <br /> CONTAACTOR�/' ^�4 F(�// �nL AOQIESS SSS /-rA'1/ ewlR SF EICF `4 PHONE/41593S'lelw <br /> Sue G�v ��ri i n4 ADDIEea 9S° iZ-lR <br /> e w �'(9rli_^_.�Z yeD ei 7YS.1-ics PNori� /3oiot- <br /> / <br /> � 5 <br /> TYPE OF W - 1:1ELLMUMPNEW WELL ❑ KPL.CEMIXF WEL LJ MONROMNO WELL lOTHER <br /> ❑ NDPAUATION ❑ WELL BVaTEM REPAIR ❑ cNOSb w*cT REPAM ❑ VAPOR EJRRACTON WELL* <br /> ❑NTN❑RRvM H!, OEFTH PUMP SET—". FIRST WATER LEVEL <br /> of wMn I�T 2-6 <br /> ❑ alT.oaeERW1:E Wai E3oEOPNveIDAI VNEl11 Y4 SDR.eoRNO <br /> ❑DESTRUCTION: <br /> INTENOFD USE TYPE OP WR11 CONSTRUCTION IRICSRCATIONA <br /> ❑ UROUSTREAL ❑0PE <br /> OON BOTTOM / DIA.OFWCLLUCAVATON el /-,4 DiA.OFCONVO 0RCASIOG <br /> ❑ DoMESPIGRBVATE 0Q/ EL uVPAWWIE -iJ-,^-4 TYPE OF CASRJ(LOTsmI (yG DIA.OP W CASING 4-11-4 <br /> ❑ NSLJC IUNICIPAL ❑OINVEN DEPTH Of OROVT SEAL ZO Pf¢T- EFECAICATON <br /> 13troDGAT10N/Aa ❑OTHER GROUT 8 L ROTALUM BByEM y .I/r (IC- amoUT DRAND NAME rte/ <br /> Ly/AOwQmNO �J wow FFAPV <br /> L MFED: [9,y— ❑ CONCRETEPEDESTALBYDFILU;w.0Y. ON. <br /> APPRGJI 0APTH J x221 LDcxm CHESTER SO%/R1'Ove PwEE yes . <br /> MOMSM COMSTRNCTOMRMWIIO METHOD: MUD ROTARYAR NOTARY AUGERy CABLE OTHER <br /> I NEPESY CERTIFY THAT 1 HAVE PREPARED THIS AP0.ICATON ANO THAT TER WOR(WRL Be DONE N ACCORDANCE WITH BAN JOAOUN COUNTY OpHANCES.RATE LAWS.AND RULES Ar <br /> RE(RULATION9 OF THE SAN JOAO H,COUNTY. NOME OWNER OR UCENN,,,AGENT'S=NATURE cVMFEO THE MULCwIMG:Y CERTIFY THAT IN THE pETOR1IANCE OF THE WORK POR YAM <br /> THRB POPHT IB ISSUEO,I SNALL NOT EMPLOY PERSONS SU6)ECT TO WORKNIAN'S COPENOISAION LAW,OF CALIFORNIA.' CCNTRAEToT4 NIM,ma OR BUBCONTRACTIIro SIONATUIE CEITIP: <br /> THE MULO NO: 'I CERTIFY THAT W THE PEHFORAFANCE OF THE WOPR POR WITCH T/IIB PVRSNT W ISSUED.1 MALL EMFLDY PERSONS SUQJECT TO WOROAAN'S COMNVISATION LAWS I <br /> CALMOA - IFN/F//////GTAyN\TJFUST CML b HORS DI AOV AHC(FOR ALL REOLatRD OFSP V TEONA AT 12M�)ASSiFSa. COMPLETE DMMmtl AT LOWER ARRA PRONGED. (' <br /> ff n .T * "< / `/ TMP SCOGc(P ._ILLI JIIT DMA CU-/ — /L7 <br /> T <br /> RDT PLAN ID, .m S.W BeW 'te <br /> T. NAMES OF STEEETS OR ROADS NEAREST TO OR BOUNORG THE PTOPOTY. A. LOCATION OF HOUSE SE'NAOE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OvTUNE M THE PROPERTY.GMHO DIMEIOONB ANG NORTH DIRECTION- EJIRMISRON OF SEWAGE DISPOBAI SYSTzme. <br /> 3. OIMEIMONEO ORUNEs AND LOCATgN OF ALL E ISTNO ANO PWROSEO S. LOCATRHI OF WELLS WITHIN MONS OF ONE HUPIORED FIFTY FT. <br /> STMICTUIES.INCLUOING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WALKS. ON THE PROPERTY OR AOJOIMHO PROPERTY. <br /> .................. ..... . ... <br /> ... ... <br /> i <br /> sem. ....: : :.. <br /> ... ...... . <br /> r <br /> ....: : • .. ..........F......i.. ....... <br /> T............................................... ....:............;..... :. .. :•. . . ;.... . ..r ..� .. <br /> .. ... .... I............ I <br /> ....... '.....i......1.....:.......t...................:.....�.......:......i. <br /> ...1......}......i... .h.. <br /> i i I J I 1 i ............... a ...�.. <br /> . . i <br /> . ...._.... : <br /> .:............ <br /> i <br /> : <br /> OWARTAEIT USE ONLY <br /> Aplla.PPn Am.Ptd BI <br /> VLAa 0.. <br /> Oran LRAaIaA BY OSEP Fu IrNPs,GP.:BY OMA <br /> D.ATrW11sr Ir�P�v[IP:•BY aM <br /> CanaaN.: <br /> ACCOUNTING only: NOI FAC# <br /> R CODES FMi TWO AMOUNT RBYTTED CHEC"MAM W[ m NY DATE P6SATNHDINCE REQUEST R ER INVOICE <br /> oJl 60 lt� 3�ib <br />