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APPLICATION FOR INELLIPUMP PERMIT <br /> SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209)488.3420 <br /> NON•REFUNOADLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CemplBli IR 711pRe[IF) <br /> APPLICATION IR RRRE BY MADE TO 111E RAN JOAQUIN COUNTY FOR A TIOMIT TO CONSTRUCT ANDIOM INBTAtt 711E WOW DESCRIBED.71118 APPLICATION Ie MADE IN COMPLIANCE WR IT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CNAPTEn 9-1116.3 AND 711E RI ANDAISDS OF RAN JOAQUIN C UNTY PUB`\t\C IWALIR SEERR•-VIICEES.ENVIRONMENTAL NEALTH DIVISION. <br /> JOS ADOnESBIDR APN/ Cil'I �(�(q\75 `1 \ / PARCEL RIZFJAPNS 4b Ok4-C,J-- <br /> OWNER'S NAME AOORFARQ _ _ `� AgNE/L\•7 L T3��1 <br /> / .�L <br /> CONIMCTO OFNV <br /> i - J G Aa 1V\CO T, lC/ IAN PONE/ <br /> A b 'AA O FST <br /> RUS CONTRACTO \ Air,0, ADORERS .ate!1 L--'-%�$5►b 5 moms I SY V V <br /> TYPE OF WELUPVMPt ❑NEW WTtA ❑PEP ACEMENT WEIR ❑l MORRTnRINO WELL[ OTII[RSR 1 /6zbll <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR L]C/K1RS CONInCT REPAIR ❑VAPOR EXIMCTION WELL I— M, J <br /> ❑N-11 n'.Ir N.P. OEPIII PUMP RET_rT. FIRST WA7FR LEVEL O <br /> RYA OF PUMPI <br /> ❑`LOUT or srnVTK�:F;WFIIII n[FO,PIYBMAITI.WFIL/ ROROA " <br /> AOE"TRUC =�.L4�,S�( �F <br /> IN IENDED USE TYPE OF W CO iIR1/Cf10N SPECIFICATIONS �� A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.or wEIL EXCAVATION `DIA OF Cd cloncnenm n <br /> ❑DOMFA/IORIWAIE ❑OIAW4 PACK/RNF_ _ TYPE OE CARUNnIRIftIMVC DIA.OF Wtll CASINO D <br /> ❑PLIMCI1,111NICmAL ❑bAVFN DEPTH OF n1OUT REAL SPECIFICATION S <br /> ❑IRn10AT10N/AO ❑OTNEn nDOUT*FAL INSTALLED BY OIOUT BRAND NAME E <br /> 3&MOMTOANO ��`�j nnOUT REAL PUMA O:11y- [IN. CONCRETE PEDESTAL RY DRIUM❑Yw ON. <br /> S <br /> APPROX.OFIIN�7LJ T[ S� LOCKINO CIIEStfn ROXATOVE PEE S <br /> PROPOSE/1 CONitRUCRONIDRWNO M[TMD:MUD ROTARY AIR nOTAnY AUGER CABLE OTIIEII <br /> I IlE'IFnY CFn11fV IIIAT I HAVE PREPARFD IMP APPLICATION AM INAT I/I WORK WILL BE DONE IN ACCORDANCE WITII SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND MULES AND <br /> nFnUTAT ION"Of TINE RAN JOAQUIN COUNtY.11014E OWNER On LK:FNRFO AOfNT'S BIONATUOE CMI lflEt TRE rOLLOWINO!'1 CERTIFY MAT M TINE PERFORMANCE OF 711E WORK FOM WMCII <br /> ,to <br /> 1 MR PERMIT IR ISSUED.1 SIIAIL NOT EMPLOY PEnSONt BUBJFCT TO WORKMAN'S COMPENSATION LAWS Of CALNORMA.'CONTRACTOR'S 1"ANO On SUB-CONTRACTMO SIONATVRE CEnTD1Ft <br /> "It fOIIOVANO•.^�I CERTIrY MAT IN TIIE PE11fONMANCE OF TIIE WORK IAA WIIIOII TIRE N IR ISRVED,1 SIIAII EMPLOY PERSONS SUBJECT TO WOROMAN'S COMPENSATION LAWS OF <br /> CALNOnry��'�/{�R M V MVST CALL f1 U11S I PNCE foR ALL BE • 1 •A ISS[I•[S OUPLEI WINO AT LOWER AREA MON O. <br /> mo.+eX� '/ ��41��j �� tm. E ry�� Q��� e.l•� <br /> C—• PleU6.0.1f FN Kh-16.0.1Ib.l.�_•Is�� <br /> 1.NAMER OF RTRF.FTS OR ROADS NFAnERF TO On"ou"mO 111E 1710PEn1Y. X. LOCATION OF HOUSE BFWAOE DISPOSAL SYSTEM On PRIMRED <br /> Z.OUTLINE OF TIIE PROPERTY.OIVILM DIMENSIONS ANO NORTN DIRECTION. EXPANSION OF SfWAOE UI8MM SYSTEMS. <br /> J.DIMMIRONED OUTLINES AND LOCATION Or ALL EXISTING AND PMOPOSFO S.LOCATION OF WELLS WTf ISN RADIUS OF ONE RUMORED rWTY FT. <br /> BTRCIVRES.INCLUDINO COVERED AREAS SUCII AS PATIOS,DRIVEWAYS.AND WALK& ON 711E ITORRfY OR ADJOINMO PROPERTY. <br /> 1 <br /> L030_ <br /> O ZDOQ <br /> F�" DEPARTMENT VI[ONLYAeFRe•Ibn AeveP1•M Rr�r.�!//!/ I b.t.� A- <br /> a—Ir+P•elbn BY DN• A-0I-P-11-By Time <br /> D«Inslbn RwPsnllen RY D.1. <br /> Cemm.r.• <br /> ACCOUNTiNO ONLY: AID/ DAC/ <br /> PE CODES DEE INTO AMOUNT REMIT IED CI /CASA RECOVED.11 DATE FER OUSEIIVICE REQUEST NUMBER INVOICE <br /> 3 s' <br /> Pub.Health Serv.-EnYro.173(3/96) <br />