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APPLICATION EOR WELLIPUMP PERMIT <br /> SAN <br /> N JOAQUIN COUNTY PUBLIC HEALTH SERVICIP <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 3K 304 EAST WEBER AVENUE,STOCKTON, CA 95201388 <br /> 1209► 489.3410 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICemplele In Trlplkefe) HE <br /> ALL I <br /> JAPPLICATION 19 REGE By MADE 10'HE MIT JOAQUIN COUNTY OAOUIN COUNTY DEVELOPMENT TRUE,CHAPTER 9- 115.3 AND THE SOR A TANDAROB OF BAN IT To JOAOU N COUT ANUMn TNTY!PUBLIC DEA IN RERVICE9.ENVIRONMENTAL HEALTH ESCRIBED.TRID APPLICATION 18 MADE IUP"ON.�ANCE W1111 DAN <br /> _CIT/ � \ C PARCEL BIZOAPN/ <br /> JOB ADORESSMR AA., �� Sa ADDREBB /I�/ � �f � PHONEI <br /> OWNER'9 NAME 'Il/�v A�C R'L' T <br /> 4/L/-iAJh IJJrL , ADDRESS /730 i 44AJAIeA/17jjR.ucF ' 5d AroNEPBm.Zu/'dL/l <br /> COwnAcTOR � "F PHONE <br /> ADDRESS <br /> "U6 CONTRACTOR <br /> ❑ OTHER <br /> TYPE OF WFLLNUMP• ❑ NEW WELL ❑ WELL <br /> SYSTEM <br /> I WELL 0 MONNORINO WELL• 13 VAPOR EXTRACTION WELL I J <br /> ❑ INei AlUT10N ❑ WELL SYSTEM REPAIR ❑DEPTH <br /> PUMP <br /> REPAIR FIRST WATER LEVEL G <br /> ❑N«v❑EbpElr ILP. DEI'iII PIMP BEt_�iT. <br /> (TYPE OF PUMPI ❑ OUTM1OP-SERVICE WELL ❑ GEOPHYSICAL WELL <br /> 0—DESTRUCTION' A <br /> CONSTPUO110N SPECIFICATIONS q A -J <br /> INTENDED USE TYPE OF WELL GIA.OF CONDUCTOR CASING C7 D <br /> ❑OPEN BOTTOM VIA.OF WELL EXCAVATION— P' <br /> ❑ INDVSIMAL DIA.OF WELL CASINO <br /> rr--�, ❑GRAVEL PACK/SIZE- TVP OF CASINOISTEEI PVC_.�� A <br /> U DOMEBTICR'RIVPTE SFECIFK:AiION <br /> DEPIII OF GROUT SEAL E <br /> ❑ PURUUMUNICMAL ❑DRIVEN GROW BRAND NAME <br /> GROUT SEAL INSTALLED <br /> --RLIY�, — <br /> OIRRroNroNIAG ❑OTHER GROUT SEAL PIMPED: 11 Yr ❑Ns CONCRETE PDE9TAL BV DPLLER:❑Yw (IN. S <br /> MONDORING /7 S n LOCKING CRESTS"BO%ISIUVE APE <br /> APPDX.DFPTN 1•' AUGER CABLE OTIIEI{__ <br /> AIR ROTARY AC <br /> PROPOSED CONSIRUCTIONI)RWNG METHOD: MUD pDtARY AND RULES ANO <br /> I IIEREBv CERTIFY THAT I HAVE PIIEPAEIED THIS AA'LICAIroN AND THAT THE WOPK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY OROINANCE9,STATE LAWS, <br /> REGULATIONSYCER OF THE BAN JOAOVN COUNTY- HOME OWNER OR IICEMED AGENT'S SIGNATURE CERTIFIER TIIE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE SIGNATURE <br /> FOR W1NCI1 <br /> �.e JPell[rr.ICWI. Cuernv. <br /> PERMIT M F T ED,I SHALL NOT COUNT - HOME SUBJECT TO WORKMAN'S COMMSAHOH LAWS OF CALIFORNIA.- CONTMCTollTOR_S HIVING OR SUB COrPRACTINO BIONATVRE CERTIPES <br /> 111E FOLLO"•�Fy THAT N TJIE 1EREORMANCE O V .>I•-- <br /> __ EXPLANATION 90.1 08112111 <br /> WHF, INC. <br /> F.O.BOX 427 6 6 9 [L <br /> OAKDALE,CA 95361 �� <br /> (209)848-4280 <br /> PAY DOLLARS <br /> AMOUNT _ J,J{rJffc <br /> es Y CHECK CHECK <br /> OF DESCRIPTION NUMBER AMOUNT <br /> DATE TO \4 /� e $ °3 <br /> z N/q7 L , <br /> ALTA u.LT .D <br /> UNION SAFEBANK <br /> MODESTO,CA CA 953 85354 <br /> 35a l) �6 <br /> 11'00669611' I; l 2 L LO L08 21:0 1, 5 i46EI 311'06 <br /> �358�3 <br /> PAYMENT i_a r��� E . (FoL: <br /> RECENED <br /> .. <br /> �1 <br /> SAN JOAQUIN"UUNTY <br /> Lp FIJBLIC HEALTH SERVICES <br /> ENWRONMENTALHEALTHDIVISION 0 Y <br /> N P . <br /> DEPMTMENT USE ONLY <br />