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APPLICATION FOR WELL/PUMP PERMIT - <br /> ' SAN JOAOUIN COUNTY PUBLIC HEALTH SERV S <br /> ENVIRONMENTAL HEALTH DIVISION — <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NON•REFUNDASLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> N:e1RpM1E M TrlplleRlR) <br /> ArIMICAT ON IIIERE MY MADF.70 FHE RAN JOAOUIN COI/NTY FOR A FIRMIT TO CONSTRUCT ANDpR INSTAtt TILE WOIK DEMCrMtD.TIRE APPLICATION IR MADE IN COMA LANCE WD If MAN <br /> J0AOtHN COUNTY DEVELOPMENT TOLE,CHAPTER#1.1116.3 AND TIIE STANDARDS OF MAN JOAOUIN COUNNTTYj /PUTLIC.HEALTH REITMES,ENVIRONMENTAL/HEALTH DIVISION, <br /> JOR AOORESRTR AI'NI/.�-/US DI��S( /�M I/'/>t 1, d./'l Or. CITY__J/O!-Y /OY7 PARCEL RI;F/AFW# <br /> OWNER P NAME_/ �h CV/'On /i�'/nj i//y p']'( m�JG!,M AOOEIERR 6cbr L�.,�i,.��(,I !(</ .S/ ,til J,.�..r4low I!S/O)7'`/J' <br /> CONTRACTOR_(�FTnr•�`t/I. G %/I/�P" -F' —�_ AopnERe('JSTI A�n�„-:.�.//S Q<II CE 5 6 nIDNE I(SrG 233'�� <br /> RUR CONTRACTOR /"(•CG/SIGH �(//s� GnG <br /> T 6363 7 P110NE�Y st;jY 7S <br /> YPE <br /> TOF WELt/PUW- ❑NEW WEtt ❑RFRIACFMENT WELL Ef J MONNOPoNO WELL N ❑OTHER <br /> ❑INSTALLATION ❑WELL SYOTFM REPAM Cl CFROSS CONNECT MEPAM ❑VAMn EXTRACTION WELL I ,I <br /> D YIE OF MMPII <br /> ❑N—❑R-0, H.P. DEPTHPUMPMET FT. [MMT WATER LFVFL __ <br /> p-- <br /> ElOUT-OF-R[RVICE WELL El OFOAIYRICAL WEI IOq ROIL ROMNO ' 1, <br /> EI OERTRIOTON: <br /> INTENDED UEE I YPE OF W CON TR[rCIION SPECIFIC HON# <br /> A <br /> INLRIATwAI ❑OPEN BOTTOM DIA.OF WELL E%C AVATION // _ OIA.OF CONDUCTOR CANIN <br /> El n <br /> U DOMFRIICRYSVAIF ❑GRAVEN PACK/RILE TYI'[Oi CARINO/RT[[L/1'VC / .�`�,T� FMA.OF YYF[L CARIMI_�/ p <br /> ❑r'VRIK_AJI/NICK•Al �ORIVEN DEPTH OF OIMt[T REAL y,/ S"f7�7 —� SIFCNK: FtL R <br /> ❑mmoATIONIAO ❑OTHER OMUT REAL INRTAULFD By ['(IS/GN'M OMOUT RRUAND NAME <br /> MftMTDNNO Of 1 fE�� £ <br /> OTUT SEAL PUMPED:[_I Y« [JJ N. CONCRETE TEOESTAL RY DNLLEM:❑V« (IN. <br /> a <br /> LOt:kNO CIERT[R MOX/STOVE PIPE <br /> AMUMS'"'CONSTlIl1C7IOM <br /> NRNSll1NO METHOD:MVD ROTARY AIR 7ARY AUOFR CARIE. OTHER /{LhH/y—�OYIC a <br /> I IE^F.Y CERT”THAT I HAVE PRFPADED THIN AFNEJCATION AND THAT THE WOW WILL ME DONE M ACCOIOANCF—11/RAN JOAQUIN COUNTY OFYXNANCES.STATE LAWS.AND RULER AND <br /> PlotRATONS Or THE RAN JOACUTH COUNTY.HOME OWNER OR LICENSED AGENT'S SIONATURF CERTIrES TIE rotJOVJINO:•1 CERTIFY THAT IN THE PFTDRMANCE OF TIE WORK FOR WIRCII <br /> IMR r•FRMIT IR MRIED.1 RHAlt NOT EMMOYFERRONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S F"NO OR RUR-CONTMCTIIO RIONATURE CERTIFIES <br /> THF FOLLOWING: -1 C IFY THAT IN TIIE FEMORMANCE OF THE WOIK FOR WIOCD THIS FERMD IR MRUFD•1 SHALL FMrLOY PERSONS RURJECT TO WOIROAAN-S COMFpd.SATION LAWS OF <br /> CALRO—A-' TH NT MUST CA{y�i. S Ml ADVANCE FOR ALL"%Gt"FD INIPMTTIO/NS/AT/trSS1 SSS 22.COMPLETE ORAWIMI AT LOWER ADFA PFOVID1713. <br /> TnE....e x_ /l///'//////// Gl Tit u 7( Ln 6 <br /> y H Ir/' D.tE� <br /> PLOT PLAN ID..w N eed.1 ee.I.i. ,Te <br /> 1.NAME.OF RTMFtS OR DOADS NEAREST TO OR MOUNDING THE r'1Or'ERTY. R.LOCATION OF HOUSE RFWAOF OI IMM IVOn r1OTOSED <br /> RTEM <br /> M.OUTLINE OFT' <br /> ITIOFERTY,OIVINO DIMENSIONS AND NORTH ONIFCi ION. EXPANRON OF RFWAOE EMOTIONAL SYSTEMS. <br /> �.TXAFNFRIONEn OWLINFE AND LOCATION OF ALL 190810 t1 AND F'IOTOREO S.LOCATION OF WELLS WONIN MONS OF ONE/II/NOIgp rRT'rT. <br /> StnUCTUDER,91CLUDINO COVERED AREAS SUCH AS PATIOS,DISVEWAYS.AND WAtKR. ON TIE TOPERTY OR ADJOIINIHO ITTOIERTY. <br /> (F7ttlaGlTr� <br /> . ., ... <br /> e <br /> :... ...e. .;....f. e <br /> / DEPARTMXRT wE ONLY / �7-`7 7- <br /> �7 <br /> neea..11e.,Aeee.ReA Rr '!'N/"C�J o.I.[D-2-T <br /> A.« <br /> Ine.R hXE+e lle..Rr D.I. PERP LMP«tle NY <br /> ONE <br /> b•.m+nen In.P�:nen Rr <br /> o.l. <br /> Cne,m.,W <br /> ACCOUHHNo DNLY; AIOI rAC/ <br /> FE CODES FLY INTO AMOUNT REMITTED CHECK/%CASH I RECEIVED■Y DATE <br /> 35 ►EIMSFfSFtIVICE REOf/ES T Nl1Me AI INVOICE 0► oNo 2�, d 29 <br /> Pub.Health SON.-EnYlro.173(1/97) <br />