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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST VVEBER AVENUE,STOCKTON,CA 95201388 <br /> Mgt 4883420 <br /> * NON-REFUNDABLE PERMIT EXPIRES I YEAR FRON DATE ISSUED <br /> ealiel <br /> APP[ICATbN OR HERE 6Y MADE TO THE SAN JOAOUM COUNTY FOR A PFAM1T TO CONS MUCT ANpl.10 hi D/OR 9,111TALL THE WOW DESCRIBED.TINS ATTLICATIO"IS MADE IN COMPLIANCE JOAOUIN COUNTY DEVELOPIAMF TOT Lk'CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUHEALTH SERVICER,ENVIRONMENTAL HEALTH DFVISIOH� E WRII BAN <br /> -POD ADTMEBbgfl API/ 3 � ,,�� ^-�– <br /> ! �-14 fL10•�� <br /> CIT-Y�Q PARCEL 91MAPN/ <br /> OWIRAR NAME_bC � / _ <br /> AD011E99 <br /> COMMCTOR__�m�'`' " RIONE <br /> ^ � — <br /> nprNv.as - uc/ [� <br /> SUS COMRACT011^_ .RIONE/' Z <br /> ADDFVSS ucii <br /> fP�� �PHONE <br /> IYT4 OF WE•LLLMLWPI 0 NTN WELL ❑REFI ACFMEPNT WELL <br /> ❑MOIRTORwO WEtI• ❑OTHER <br /> c``•n E] MOl'ALUTION ❑VYE11. STEM REPAIR ❑CIOe1 <br /> ..0 ❑NeVr 0 Wy.lr N.P. S CONNECT REPAIR ❑VAPOR E%TRACTKHJ WELL I J <br /> (TV"OF PVMPI i.--- DEPUI PI1MP aFT(f� FT. FIRST WATER LE`/EL <br /> O <br /> OUT OT-RERVICF Wttt ❑010MI RIC.At Wit.f_ ❑ ROA.BOTSEIO <br /> ❑DEBTRIJC Z ION• A <br /> INTENDED VSE TEP{0 WELL COMS/RUC TION 6PECNICAilO MS <br /> INDUSTRIAL ❑OPEN SOTTOM TNA.OF WELL E%CAVAl10N A <br /> DOMFSTIC/PRIVAT -- — _ DIA-Orr CONDUCTOR CA8Mp 0 <br /> E ❑DM VEL PACR/St�f iYif DF CA61NG/P TEf UPVO <br /> DIA OF WELL CASINO 0 <br /> RIB[b A.IUNICRµ DRIVENCIA <br /> Of GgDUT SEAL_❑IRRIGATK]NfAO SPECIFICATION S <br /> ❑OTHER GROUT REAL INRTAIJ_ED BV <br /> ❑MOMTOFONp pROIIF fRAND NAME F <br /> TR/N <br /> �qq C/ f SE <br /> GROUT AL H4D:11y– LIN. CONCRETEPEDESTAL 8y DRALER:❑y ❑N. <br /> APp10%.DEIfH�O�7' s <br /> /// LOCRINO GIIEHTER fOk/aTOVE!TT'E \ <br /> IaOPOStb CONSTRMI ONA"LUNO NTETHOO: MUD ROTARY S W <br /> _ ARI ROTARY AUGER _CAS[[ <br /> 1 HERESY CERTIFY THAT I HAVE PFEPAMEO THIS AIPIJCATbN AND THAT 111E WINK WILL at DONE IN ACCO/IDANCE WR!E BAN JOAOVIN COUNTY OPYANANCES,STATE UOS,AND RVIEe AND L,J <br /> HEOVLATgNB OF THE BAN JOAOUIN COVNTV, HOME OVMtq OR tICFNSED AOFM'B SIGNATURE CF.RTIFIES 7HE FOlJD4YIRt:'1 CITRIFY THAT M TtIF PEW OIMANCF Of THE WORK iap yM/1CN <br /> THNI PERMIT 181SSVED,I SI/ALL NOT EMTLOY PERSONS SUBJECT TO WORKMAN'S CONPENSATTON LAWS OF CALIOR141A..CONTRACTOR'S HIRING OR SU6COMMCTINO SIOTlATVRE CETIFIFS <br /> THE FOLLOWING: '1 CERTIFY THAT IN T14F PERf0flMANCE OF TINE.WO/R FOR WHICH THIS PERMFF IB ISWED,I fNALL EMPLOY PtRBDNS SUBJECT TO WORIWAN'S IVIG S AT E UWS Of <br /> C <br /> At IFORNI PPUC ANT MUST CALL 2 gVRt IN ADVANCE FOR ALL MOUNIm INS NS AT 1"011 4"442.COMPLETE DRAWING AT LOWER AREA P S C OMP <br /> SIS.W x G, C TIIIe <br /> Dee <br /> PLO/INRIIII ROElrwv[e SaJ.t Beeth '1P_ <br /> I.NAMN OF STIEFFTf OR ROADS NEAREST TO Oq BNDOUG THF PPERTY, A. LOCATION OF <br /> T.OUTLINE OF THE PROPERTY,OIVINO OIAENT <br /> NBNS AND NORTH DIIIECTION. HOUSE RAVAGE dSPOS/y,SYSTEM GR PRDTq SED <br /> T.OIAFNBIONtD o1Tf UNEs AND LOCATION OF ALL EXTSTMO AND PROPOSED FXPANGMN OF SEWAGE DISPOSAL Sy STEMS. <br /> STRUCTURES.U4CLUDING COVER¢O S.LOCATION OF WELLS WTTMN RADIUS Of nNE HVNDREO FIFTY FT. <br /> ARFAf <br /> IT <br /> ws PATIOS.DPRVEWAYS,AND WALxf. ON <br /> JOIMNO PROPERTY. <br /> Vic <br /> 4. <br /> . .. <br /> :.. .. : 'PA- <br /> Lj 11'4 <br /> '— ALTI4SEP,VICE,$ ' <br /> IKIARIMENT VSE ONLY <br /> APMce,b..A--,M Pr _ -7 Ar Z <br /> be,A k.wee,b.r er Oere E1xnP Inep de By M1. T 'P / <br /> Or+,I,RIb.I.,,Peetbe Py <br /> Cemm(� <br /> ACCOUNTING ONLY: AIDI FAC/ <br /> K CODES FEE INTO AMOUNT 11EN11TTED CIIECK 'AIH RECEIVED TRY DATE PSEIST/SF/IIRCE AMIT <br /> CEOSpIf/lei <br /> Q <br /> Flub,Heahh SON.-Enviro 173(3136) <br />