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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> PoENVIRONMENTAL HEALTH DIVISION <br /> P, OX 988,904 EAST WEBER AVENUE,STOCKTON,CA 9S2013B8 <br /> (2091 4683420 <br /> MOM REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> ION,1. <br /> AEF{ICNbN IB IIfRfBY MAGE 10 THE RAN JOAOUIN COU ,FOR A 2MryT TO CONSTRUCT APDMA INSTALL THE"FIR DFACMBFO,THIS AMICAIMN le MARE IN COMPLIANCE WITH BAN <br /> JOAOUM COIIMY DEVELOMENTTOM."AFTER 8111 5.3 AND TIES STANDARDS OF&W MAWIN COUNTY MatW...ALTU BFT/ICES.ENNIbNMFMAt HEALTH DMMN. <br /> JOS ADDPESSNR Am, o-4 – ;.g0.- of Cm U = <br /> OWNFq'B NAMFNoT.g Z?4&S%O !' n /( V. 1 FIF ZC'�pA11CFL MiF/APNI <br /> �'J..��-- —'+L<— a� • ADDI[ae 'T J i RHONE V–/ - <br /> aFXQEMUfi`UMP, <br /> CONTRACTOR 12—MrA NU/ ,1/ (nwste.er�3vr5 <br /> ADdE:ceFr-�(/QF'b <br /> FIRMS <br /> BVe COMMCTOP/y//rL/l�"LLJy�(/JYY(,r ENwrryU)t/Fjd/y¢� A.OYUF O WELL ❑PEMACFMEM Wflt 3 <br /> M...CCNGWfllF ❑OTH[R <br /> ❑drt.LIUTbN ❑WELL SYSTEM REPAIR <br /> ❑CPOSSGONNF[T MpAIq ❑VAMgFITMCTXIN WE0.1 <br /> RYIE Of MMP ❑Nwv❑Mptlr N.P. ORMI MMPSET FT. J <br /> 1 �_ iIReT WATER tm O <br /> ❑OUT-OF SERVICE WPH <br /> ELL ❑GEOYSICAL WELL I R"RUNS❑pf BTRVGTION: I <br /> INTENDED Vef TFE OF CONSTRUCTION SPECRIC }IONS <br /> ❑INOUSTMAL ❑OIfNpOITOM <br /> ❑ DIA.Oi WPALbN ( CIA,OF CONDUCTOR C_A1�b^� <br /> A <br /> rqFAVU <br /> DOME tlRE RACK/S4E T4OCAUNOAODNCIA.OiWCASAlb❑RRIILGHUNbIpAI DGvER OFpiN OO <br /> OF SROM MAL❑ MIRQAMN/AO ❑OiNM SRECIRGTION A <br /> ••11 OIbM BFµMSfµLFO pY SROM SMN0 NAME <br /> Ox1TOR1xO Y 'MW%tALPVMFED:Ovw ❑Nef <br /> CONCFFTE IEpFrtAL SV OWLLFq:O vw L]ly S <br /> APAGK,OETN IOGKINO CN[BT[P e0%pROVE RIE <br /> MOpOFfII COMFTIUCTOMIdEWMO Mrt O' MUp MTAwS <br /> Ab ROTARY AWfp CApLE OTNFq <br /> I NF�ESY CEMSY THAT I IUVE 1: mil I AMLICATbx ANp THAT T11E W4Rt VOIt eE CONE d ACCOWANCF W1TN MM JOAWIN COUNry 011DINANCf,STATE UWe,AN VIFB NO <br /> REGULATION. <br /> OFUED.I MAIL <br /> COVNTV.HOME OWNfp CAVCEN6[O ADEN '.SIGNATURE CERTIFIES THE PoLLONANO:'I CFRTSY THAT M THE PERFORMANCE OF THE Wq FOP VMICN <br /> 11118 PRMR IP MBVFD.1&1µt IbT FMROY TERM"BUPRCT TO WORKMAN'S C..M.ATON IAWB OF CAHfOMU.'COMMC1Op'S HIpNb OF pVe{OMMCTINO&ONATVRE ,YYN FS <br /> TIIF fOLLOW'INO: '1 CFTI THAT d TIIF FEAT NAANCF Of TIIF W9R(FOp WIGCry TMS RIM1T IS IBSV[D.1 SHALL fMR.OV M"I'MASSOa BUSIND TO WLCONTG C COMPENSATION MON TUR,UWM Of <br /> CALRO TI FFUC Ir M C UM IMA ANCF[OR ALL RFOUIgID MSM NS AT ILMI Mi�f C`OMPETE DRAW M AT LOMB AFEA RAJ EO, <br /> 6I.wSK nn. /"AE=G:T�GT �AEE/C[.�T/Sj' pN. S ZS <br /> nOr FUx ff n_M%..1 S..N •U, <br /> 1. NAMFBO STRFFTB OR MAOe NfA OOfl SOU <br /> NdNO THE IPJmE . <br /> E.OUTLINE OF THE , LOCATION OF MUST SEWAGE d8108µeYTfM OR RbIgSFD <br /> TJPRry,OMNO UUMFNBIONe AMCANNORTH DIRECTION. <br /> J. DIMENSIONED OUTUNI S ANp LOCATION OFµL EXISTING AM PROPOSED ENPANBbN OF S AOF dBlppµSYrtfMe. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,ORVEWAYS,AND WALKS. S, LOCATION OF WELLS WTHIN RADIUS OF ONE HUNDRED FIFTY R. <br /> ON THE FOMM OR ADJOINING Rb1FRTv, <br /> e/L DpAMwrMFOxlr <br /> Appll,btl AewWey / <br /> a,.M Inpwllen er D.. R p W.Ml n eY <br /> pM. <br /> 0.0—Inpwllw er , <br /> C.m,Rwlr:�PV'{'L%� /1�0nD✓44 QI"(i11i.) �Anr w/�A n.l. <br /> LiAls wIC1�a od f Qd Y 2J4Ws �n� <br /> ACCOUNTING ONLY: Alm MCI <br /> FF CODE) FEE INTO µ10UNTRWITTED CHICKIMASN RECEIVES SY DATE S[IVAIT/SEIMCB REQUEST NUM SA INVOICE <br /> 9—D 24 950 9.5. 35b 5 <br />