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O�S 6?eta <br /> APPLICATION FOR WELL+PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 789, 446 N.SAN JOAQUIN ST, STOCKTON, CA 96201.388 <br /> [2091 488.3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICRRIpktp M Towlestu <br /> AMICATION Ie HERE BY MADE TO THE SAN JOAOUFN GGUNTY FOR A PERMIT TO CONRTRIICI ANGOR INSTALL THE WORK DESCRIBED.THIS APPHCAl10N IS MADE IN COMMIANCE 1VI111 THAN <br /> .pAWJN GOINYFY DEIRLp#{FNaY Fr fl F,d(r��P`T{ER 8-1 I 6 3 AND THE STANDARDS OF SAN JOAOUIM COUNTY PUBLIC HEALTH SERVICES,ERIVMONMENTAL HEALTH DIVMION. <br /> "a A'wnEBBJGR AMI 34 0� �/�/L S� �"I�rn M/ yr" L��� CrfY �4(r� a('`/ PARCEL WZEJAPNI <br /> ONNER'BNAM�JC..O �Y.I L�C3} e5 T"' // r ! III, <br /> r,AI�A ,}�JIOIal-3 <br /> UJ J11GI'1 I- iLooPROW 1 It y 7-iII,d <br /> COrIrWrCTOR J'Vf C--TJ„' C,. 22A4�; <br /> LICr <br /> AIXNEbb ' 1 v'L. CS 7u'}o3tPIIOw'(llIO 6$0-4gW2- <br /> TYPE OF WE 'TP: ❑HVW WELL ❑RER/ICTMENT WELL ❑MONROIYNRwEH_, D OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CTOSS-CONNECT AEPAIR ®VAPOR EXTRAC7ON 41E+1 l_1__ <br /> ITYTE OF PIJLLPI 7 N-11 <br /> R•OW H.P, bEPTH PUMP SET FT. FIRST WATER LEVEL_ 0 <br /> ❑OVI-0E-BEIIIA[E wELt ❑OEO11rY61[AL WEL!d � SDIL BORING_ d <br /> ❑DEBTIIUCTgN- <br /> MENDED lia TyraO, COFtGTRUC7IGNyECIFICAIIONE A <br /> ❑RNDURTBIAL ❑OPEN S!ITTOM DFA.OF IIFLL E,p CAVAI pN DTA.OF CL!HOUCfOR GAbf fNO •' p <br /> ❑DOMESTICMMVATE J❑I ORAVEL PACKM12E TYTE Or CASINOr8TEEuwC ?vC' DIA.OF WELI,CARING LII / R <br /> ❑PURUIM <br /> CUNICIPAL U DRIITN TJEPTH OF GMHT OFA (IF <br /> SPECIFICATION a <br /> ❑II�EOATIDN/AO ❑ATJIER <br /> ❑ <br /> }�FryJqI OROVf SFAI NL,PALLED SY Y 1 1$. ddp1FT BPUUJD NAME .t_ E V j,7'0-FT O A},r'16 IY DOOM SEAL PUMr40:❑Y- Elm. CONCRETE PEbESTAL SY DWLLER:❑Y_ ION. 3 <br /> APPROX.DEPTH_ []r _ cKIFIIT CHESTER RFYDVE PIPE__^ S <br /> FROrorlb LONrrI{(11f;T/ON/dSC111FO MErHDO: MLAO NOfAT' AM ROTARY _AUOER ICABLE_O1 HER <br /> I IERERY CERTIFY THAT I HAVE PREPARED 1HIS AMICATION AND THAT TIIE W04W 15nLL RE DONE IN ACCORDANCE YYIfN RAH JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND RIAS,AND <br /> TwBFE'RFffT <br /> FIEGUL RAffr I OF THE SAN JUADIJR{COUNTY.HOME ONINEA OR LICENSED AGENT'S SIGNATURE CERTIFIES 1HE rOLLCWRJO:'1 CFRTNY THAT M THE PFIEOIMANCE Of 711E VOW FOR WHICH ' <br /> S lrStlEG.f WAL1-htrYF OYP'ER NR EUBJFCT TG%VMKMAN•E COM►ETMATION LAWS OF CAUEORMA_•CONTMCTOWB MWNO OR SVB COMJLAC71NO rKJNA7VRE CEPRIFIES <br /> THF FOLL01MN0: 1 CERTIFY THAT 111 71 PE O ANC[OF E WGF'F[FDR WHICH THIS PERMIT N ISSUED,1 S!IAII EMPLOY I+EHFIONS SUBJECT 7O WFHIIDAAM'■COM ■AH6N t/lWe ES <br /> CALIFORMA,' P ANT ST 7r E1w AWA FGR,ALL RSGIJIIIEO INSI'ECTgNS1AT if a1p'q.l.7r] COM(P/yETVE. WINGr. 1,�ATI1TL'OWER AREA P11q pEb 1 <br /> shl—I K TYM �• ,`Y j� V.V7 o I W V <br /> ROT PLAN ml—h Sa•Inl 9-1% •IF <br /> 1. NAMES OF RTPR"S OR ROAD,NEAREST TO OR SCUNDINO THE PROPERTY. i. LOCATION OF HOUSE SEWAGE Di"SAL SYSTEM OR PROPOSED <br /> 7. 0UTUME OF THE PROPERTY,GIVING DIMENSIONS AND NORM IIDECTmN, E7IPAHBION OF eEWAQE DISPOSAL SYSTEMS, <br /> J. <br /> DIAILNBIOMEO GUTHNPR AND LOCATION OF ALL E7Gb ma ANO P7Orowb 1. LFICATPOH OF WELLS WITHIN RADIUS OF ONE HUNDIED FIFTY IT, <br /> STMICIURE8,INCLUDING COVFFVO AREAE VJCHHAAE PATtOB,DREVEWAYS.AND WALKS._ ON THE PNoPERTY OR ADJMINO H1DPE11TY. <br /> t/f,_--(. <br /> MW-4 Mw-3 <br /> �{�<D.3� cpm 99 <br /> NOT LIEASVEO s[RvIC[ <br /> srAnOM NOT MEASUREDq!I <br /> r� JIVLDIHC <br /> I I <br /> L-I PTD-I <br /> DISTZMSER <br /> um 703 <br /> MHGLR�AOWo . <br /> MOW IAN1f —1 P-, FTD•1 PTB) <br /> I <br /> 18" 70 <br /> F _ 1 @N610 GT JJ 90a"O<0�'g <br /> t I EASURED e . <br /> I <br /> M��n�I PN r-J�FUW-1 <br /> P018- <br /> 63 0 `-`,,,�r�1. <br /> aF 0 0. NDcO. No <br /> NOT ✓aFASURED <br /> PLNIIER <br /> DRNTNAr <br /> gINEwAT <br /> 1RAwsronUER <br /> _.II <br /> DEPMTMENT THE ONLY <br /> AMN"l Nn Aftwtmd Qy�[/�y��f� // G <br /> y <br /> O•h / Arw <br /> Oreu1 ImP•PII•n,TPIn•P=11I <br /> D.I. -P u .RY b.l• <br /> O..errsUen L+rp.•Ilpn RI O•FE <br /> Comm�H: <br /> ACCOUFRIINO ONLY- API, EACF <br /> PE CODES FIN INFO AMOUNT REI47TE0 CH RASH RECBVED■T DATE PIMIFTNERVICE IIEOUEST NURSSI IWUICE <br /> �D I I Zr <br />