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I h y APPLICATION FOR WELLIPUMP PERMIT ` <br />w w R SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ©o _/ o I <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 95201.388 <br />(2091488-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(CempIFH M TrIpOPBLFI . <br />JOAQUIN CO N HENS EL MADE TO THE BAN JOAOUN+ COUTJTV FOR A PERMIT TO CONSTRUCT ANDpR INSTALL THE WON( DESCRIBED. THIS APPLICATION IS MADE INCOMPLIANCE WITH BAN <br />JOAOUIN COUNTY DEVELOPMEM2TRLE2CRAFTT"E�R 9.1115.3 AND TIME STANDARDS OP BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION, <br />JOS ADOnEee/On APNF_ I6 s2-3 (5 + BAl��r crrr �dC • . <br />n� �� PARCEL SIZE APNI <br />OWNER'S NAME �L ADDREBB PHONE ilI rI i j/y (/t <br />COMMB CTOR�/�L � AOD11ES8 2o2��cy,a,�nrlI � l� ,7?Or�q�% ' <br />SUB CONTRACTOR <br />/ CTOfl ADO/IE88 <br />LR:F PHONE B <br />TYPE OF WELMMP• NEW WELL ❑ REPLACEMENT WELL ❑ MONITORRiO WELL I ❑ OTHER <br />- ( 111Nµ ALLATgN El WELL SYSTEM REPAIR ❑ CROG"ONNECT REPAIR ❑ VAPOR EXTRACTION WELL F <br />LlRNMr IIA. DEPTH PUMP SET <br />RVPE OF PUMP)_FT. FIRST WATER LEVEL. O <br />11 OEeTflI1CTIbN: <br />ElOUT-0P-SERVICE WELL ❑ OEO%IYSICAL WELL F 11D. SONONNO <br />B <br />_ <br />-...,_ . DEPARTMENT USE ONLY <br />... : ....:... <br />APP11-ft n A.. ow By ^a+i-eF.^-....ate- .,,. .•ALC+....+... _ -...- _a.:_e+w.. Y....:�...�a .,. ,.�. <br />.:......:......:.......:... <br />O:eul ImOePllen DY. ��/�A�iLG�� • -/ !O/% P—P InpmIlen By ' -•r-- —^—r_1 "— <br />U <br />De.lncllen IMPenI BY - / <br />Deb <br />Cemmp:le: <br />ACCOUNTING ONLY: NOF FAC! <br />PE CODES FEE INFO AMOUNT REASTTED - N F/CAFII RECEIVED BY DATE <br />P91AB7/6EAVICE REOMIEti NUMBR31 <br />INVOICE <br />Or <br />7 <br />D31733 <br />Fut). MOaltn 58rv. - Enviro. 173 (3/86) <br />