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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAUUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 3M 304 EAST WEBER AVENUE,STOCKTON.CA 95401588 <br /> 1209)4083420 <br /> RON REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> IAmPMM In TrIPIkBt.) <br /> AI'PUCRmN It HEN BY MADE TO THE FAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANIMA INSTALL THE WORK DESCRIBED.THIS AMUCATRIN le MADE IN COMNANCE WRIT BAN <br /> JOAOUIN COUNTY OEMOFMEM TGIF,CIEAPTFR 8-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERNCEB,FERAMI MENTAL HEALTH gWANIH, <br /> JDs AtMMw AAP' ;}y EWcow CJEWS;c CRY 9rrOeKITEw CA PAwEL aRE1APlFpq}_y)-¢q <br /> �r � 44Go8 <br /> OMMFR'B NAME �CTFI.MM1 DREII U[Auma E)ECFUO CIO AMIEnn IROO P&dtL kT�IZE _ALN>my9,MVMLLA to AroM 10) 652-4.546 <br /> D aNAtY T. OR<OfNn LJ, ITl P2e.Ie4 NAEf4 <br /> �SMIMBTGM1 !!. N � .QEC N 'ABOIIEBs LIEF REBIIEI <br /> (' <br /> F3Ar <br /> Aue1:OMRAcTon$Hso .nJ. EryLDnAnDAI ZMc. ADDRESS 2_3Ly"Q141E✓MODAV SOSIOW CA LICA 5ILUN PROM(dW)Wf-/fill <br /> TYPEOFN'ELIRIMP: 0NEWM4LL ❑RRACFMFM WELL ®MONRO11INOWFLLFMW-100 ❑OTHER <br /> ❑INSTALLATION ❑MIL SYSTEM REPAIR ❑CweRCONNECT REPAIR ❑VAJOR EXTRACTION MR ✓ <br /> ❑Nw 13 SAFl A H.P, OEPM PMP SET_FT. FIRST WATER LFVFL O <br /> RYPE OF PIM% <br /> ❑DVT-011HENCE`h4ll ❑OFOAIYBICAL WFLLE ❑ wRBOPo1M1 B <br /> ❑DFMRVCTION' <br /> INTENDED USE TYKOFWM COINIMUCTIONEPECVMATIOM A <br /> ❑INDUSTRIAL ❑.MNwROM DIA.OFMLLEXCAVATION IU-INCH OA.OFCOMUCTORCASINO NIA O <br /> ❑MMERTIOMUVATF ®oMVEL PACKAHZE 0-e1-19LN "MOICAMMORTEFINVC Et. STEEL DIA.OFWELLCAMNO 'I-I"W O <br /> ❑MMICMUNKIPAL 11 MYTH MPTHOFOMMM'AL 6A-CfF SFECTICATION CYMAAIT'4fAh1V4E s <br /> ❑IMUOATIONIAO ❑OTIEER GAMUT SEAL INSTALLED IK1gy�;eti�_eU VI, OMM BRANO NAM_MIA E <br /> ❑MONROPoNO OMUT MAI NMrtO:0 Y- 11 R. COwPEIE FEDESUL BY DPoLLER:®V. ❑Ne S <br /> Amwz,Ol"" 7(1 Ff B(ld.J AswuO SOt OXt L.CS. R CHEAT..w%IArovE ATe NO S <br /> POMMUS CONFMMPONm LUNG METHOD: MUD ROTARY AIR ROTARY AVOEA CABLE OTHER <br /> CM <br /> 1 REVS,CERTIFY THAT I HAW PREPARED THIS MYLCATION AND THAT TIRE WEAL WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY OFEMNANCE9,STATE LAWS,AND RUBLE.AND <br /> REGULATIONS OF THE BAN.OAQUIN COUNTY. HOME OWNER OR LICENSED AOFM'B SMNATuoE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THERNORMANCF OF THE WORM FOR WHICH <br /> THIS]ROME IS ISSUED,I SMALL NOT EMPLOY RRSONS SUBJECT TO WORKMAN'S COMFENSATON LAWS OF CALFOPNA.'CO RRACTOWS HIPoM OR wBCOMMT 71M AIONATVIE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE RKOOAANCE OF THE W ROR FOR WHICH THIN REAMER IB ISSUED.I&HALL EMPLOY RnwNS SUBJECT TO WMOAAN'S COMRNSATON LAWS OF <br /> CAMORM/A/.////�]/r�E.F,,A MW T CALL 24 HOMB IN ADVANCE FOR ML MOMRm INSRCTgE0.11 OFI.B6- 23.COMPETE DRAWER AT LOM'R ATEA PVMOw�.p <br /> eb^d2 Vr.' �� QS g9'tAf kr TMH.MANA6IA, GMmN,A..CJtPEJY1RR.N.l 1NL. Dw. <br /> KIaA. z1AzF nor FUN M,..,n S.NM PoN.I-IFICAL 'm Ate-FftT <br /> 1, NAMES OF IRMETS OR MADS NEAREST TO M MUNDANE THE MORR Y. S.LOCATION OF HOUSE WINACE MONISM.SYSTEM OR PROPOSED <br /> 2.OMLME OF THE MJRRR.OMNO DAMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE OIBMAAL SYSTEMS. <br /> 3.DIMEWONED OMIIMe SERO LOCATION OF ALL EAIpIM AND IMMSTO S.LOCATION OF WELLS WITHIN RADIUS OF OM HUNDRED FIFTY IT <br /> STRUCTURES.INCLUMM COVFPEO AREAS SUCH AS PATIOS,DAMWAYS,AND WALKS. ON THIS MORRTY OR ADJOINING PROPERTY. <br /> wn V VIIIR3s <br /> MOM LI <br /> I.1O K.IQ N� xWA <br /> o <br /> VA* x <br /> Mwd 'I VNCMH%MO]L <br /> WA <br /> HMI <br /> G <br /> FAIAR N." S 9' *IF <br /> Cloning YIH e s <br /> MW-OO Hwr6. <br /> LT<.mn - • I� Mwu <br /> Cn 3uIiM UFI6RPJPJLUe <br /> MwPO Mwa xw.H PP <br /> LIxCOLN CHRIS.TOCROH.CAUF.. iA <br /> OW.3: <br /> MOIDmM ry[.Ad vMA UWA ANS <br /> � Atl1.FPrtH1NIMI1gMp 10CAnOM <br /> OnMI.RM LEVINE•FRICKE <br /> I <br /> OESMTMFNT DUE ONLY <br /> AePlla.11en Aee<lad Br DN. <br /> a..M IMPKMR er_ ml. WPIC NwPSSan Br D.1. <br /> D..Iwwne.Inpmllee er D.1. <br /> D.mmnr.: � WeLss a�t^a✓ D. � <br /> AOCOUNTIM ONLY: MDI LACI <br /> PF C... FEE INFO AMOUNTRDATTED CMCRIOAME RECOVEO BY DATE S ll.TRYICE REQUEST NLMSDI INVOICE <br /> 290 13 10.25 I <br />