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'11PLICATION FOR WELLIPUMP PERMIT .. <br /> ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N SAN JOAQUIN ST, STOCKTON,CA 95201-388 <br /> (209)4883420 <br /> NOW-REFUNDABLENOW-REFUNDABLE PFAUrr WIND I YEAR FROM DATE j2$VE0 <br /> Mu*lEh IB TF1pRaW <br /> APPLICATION I2 HERE BY MADE TO THE BAN JOAOUM COUNTY FOR A PERMIT TO CONSTRUCT ANUMR INSTALL THE WOW DESCRED ITHIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUtN COUNTY DEVELOPMENT TITLE,CHAPTER&1 115 3 AND THE ST fo'fy1SAII Jo COUNTY RAW HEALTH SERVICES.ENVIRONMENTAL HEALTH WYMON <br /> Job ADOREl.gRnAPMI r�4� 43I P�2oP �'4ry S Lotj ¢ <br /> OWNER'S NWE�1 � PARCEL B�IAFNP <br /> Fo eD T s220 PPaPEb.7 <br /> C L- A�mrc48 -! Lr � PPI?M 3 5- <br /> ' weCONTRACTOR Z.LrM EZ�gnjZ A.PHGNE,g v- <br /> TmQpmmLm-VMF- ❑NEW WELL ❑#A.ACEMMT WELL ❑HOMITO/YNO WELL/ ❑oTHER <br /> ❑MSTALIATION ❑WELL wnmEm REPAIR ❑cRo2EOONINECT Pc Am ❑VAPOR onwwTioN WELL' / J❑New 13PAP.& H.F DEPTH PUMP KT,,,,._FT PMT WATER LEVEL__. � O <br /> fTYPE OF PUMPI <br /> ❑OUT-0FiEAVICE WELL ❑OEOPRYSICAL WELL/ SOIL pO1ElIQ S <br /> ❑DESTRUCTION I <br /> NT NA <br /> 11ENWSTPAL 13OPEN BOTTOM DUL Of WELL EXCAVATION DLA,OF CONDUCTOR CASLNO 0 <br /> ❑OoMESfIC/PPIIVATE ❑G11AvEL PACIUSL2E TYPE OF GASUNtNlSTEELJpVC DIA.Of WELL CASINO TAp <br /> ❑PUBLICARINICIPALINDEPTH OF OROUT SEAL SPECIFICATION A <br /> A;=.-Nl- GROUT SEAL STALLED BY GROUT DRANO NAMEGROUT SEAL RIMP9V 13 Y� W CONCRFKPEDESTALSYDRILLER,I3 V. ❑N.ArwnlL. LOCKING CHE07ER ROFOBOXNMVE�PI/ <br /> PSED CONETRUOTN MAMLLRNO METHOD, MUD ROTARGER <br /> Y AIR VOTARY AU _J[ __ CASL7 OTHER <br /> 'THE <br /> CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE W ACCORDANCE WITH SHIN JOAQUIN COUNTY OAOINANCEE.STATE LAWS,AND RUIEE ANO <br /> REOULATIONS OF THE SAN JOAOU01 COUNTY HOME OWNER OR LICENSED AGENT'S SIGNATURE CEMIFIES THE FOL OVNNO,T CERTIFY THAT W THE PERFORMANCE Of THE WORK FOR WHICH <br /> THIS PERMIT ISISSUED I SHALL NOT EMPLOY PERSONS SUBACT TO WORKMAN 4 COMPENSATION LAWS OF CALIFORM& CONTTLWTCWS HW&"OR SUFCONTRACTIN0 SIGNATURE CERrii1E0 <br /> THE IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENATION LAWS OF <br /> CALIFO Y CALL 24 HOURS W ADVANNC■FOR REQUIRED INSPECTIONS AT QON 44841172 COLM{ATE DMWINO AT LOWER AREA PROVIOW <br /> s <br /> woMe A oe. i <br /> NOT PLAN 0—m go"Sew m <br /> 1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY 4 LOCATION OF HOUK SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2 OUTLINE OF THE PROPERTY OIVWO OW04MONS AND NORTH DWECMN EXPANSION OF KWAOE DISPOSAL SYSTEMS <br /> DIMENSIONED OUTLINES AND LOCATION OF ALL E)uun NO AND PROPOSED E LOCATION OF WELLS VMTMN RADIUS OF ONE HUHDPIM FIFTY Ff <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS DFMWAYS,RENO WALKS ON THE PROPERTY OR A6101NU10 PROPERTY <br /> DEPARTMENT LMR ONLY <br /> AppEeeWn AOe�PM 6T Deb MM <br /> I <br /> Grout"P.eim BY O.N. PL V-mq b EY D.m <br /> D-w.,Uen In.P..11en BY D.m <br /> Commend <br /> ACCOUNTING ONLY AIDP FAC/ <br /> K CODE) P"INFO AMOUNT REMITTED CINECRoicASH RREGEIVm BY DATE re"Tolumms REQUEST NUIMSiN INVOICE <br /> 1 s <br />