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APPLICATION FOR WELL/PUMP PEP <br /> S. JOAQUIN COUNTY PUBLIC HEALTH b. !ICES <br /> ENVIRONMENTAL HEALTH DIVISION jr y! <br /> 304 EAST WESER AVENUE,STOCKTON,CA 95202 0"r - <br /> (209)468-3420 <br /> NON-REFONDA6IE PERMIT EXPIRE!1 YEAR FROM DATE ISSUED - <br /> {CompMEb In Tilpikatl) <br /> APPLICATION le/IErE BY MADE TO 714E SAN JOAOUIN COUNTY F AFE1M1[TOS_SONSTRUGT AND)OR INSTALL TIIE WORK DESCRIBED.This ARLICATION If MAGE IN CommiANCF WFIN GAN <br /> JOAPOIN COUNTY GEVELOP1r1ENF THLA,CNAPTER 0.1115.3 N .TIIE �O.D!SJf AOI/IN COVFRY RIGLIC HEALTH OEflVICE9,ENNRONMENTAl IIEAL711 OMG10N, <br /> ion ApDflFeemn AT?N//Qa) 7/J'4-.3F./Z N�Lgz' i,i c. CITYt 5r,eA�1 c/1 PAFICFL SHENIpHe <br /> OWNER'i NAME L AWIfEBS371 SII/�Z LCFr�S GTr� y�r�'� PHONE F I"r/OJ2Y/'J-Y <br /> CONTRACTOR al"IEWA Qf'a /�Jlj ZA 5�fi� ADDRESS rX0 NMislL Pd /S4y.i�1ci U1RCE 7"MNE a Cf/CJ717'rSDo <br /> BUS CONrR lOR- �I-(-F/!S G•�CpYi(L wpuREee U�CIf�� MIONE! <br /> TWX OF WFLVFR W. Q FEW WELL ❑RERILCEMENT WE11 ❑MONROnuq WILL♦ ❑OTIIEM1[..!F� � <br /> t❑Y MGTrA1LATION ❑WEIt SYSTEM REPAIR ❑CROSBCONNECT REPAIR ❑VAPOR EXTRACTION WELL/ J <br /> LJ Naw❑IYP.k H.P. OEM 4VM1`SET FT. FIRST WATER LEVEL O <br /> ITYPF OF P'LIMM r� <br /> L1 OUT-Or-SERVICF W'FLL l-T P[PRIYSIGH WELL E Q BOIL BONNO B <br /> ❑DlSTRUGTION; <br /> MTF,OFp UEE TYp O ca Nbin 10 SPECIE A IONS A <br /> ❑M ILSAL ❑OPENSprrOM DIA,OF WELL(9CAVATON DIA.of CONOPCIOR F ASINO 0 <br /> ❑WMESNCNlSVATE ❑GRAVEL PADA/S12[ TYPE OF CASMOMTEFLJpVC DSA.OF WELL CA 3" O <br /> ❑PuniacmuMCIPAL ❑DRIVEN DEPTH OFGFIGUTSM 7� SPFCIfICAIION 4 <br /> ❑IWMOATIONIAG ❑O7HIR GROUT TEALIN47ALtEDryeEYr(f GROUT PRAND NAME f <br /> ❑MONroton1O OROUTSEALPVMPFOIFay— ON. CONCACTEPEOEEIALAYDRBLI[R❑Yw ON. $ <br /> AFRIPA.owl" L/— F0 LOCKM CftEsrE11 DOXISTOYE RPE s <br /> FROMME0 CONS TFIUCTIOWDIVLUNO MXTHOV:MUD ROTARY AM ROTAAY AUGER CABLE <br /> I NEREBY CERTIrY THAT I IIAVE PREPARED TING APRICATION AND THAT 711E WORE WILL of DONE IN ACCORDANCE MITI SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RVIEG AND <br /> REGUTA7101,111 OF Till SAN JOAOUNI COUNTY.HOME OWNER OR LICENSED AGENF'S SIONATu11E CERT bots TIIE FOIJOWINO:'R CERTIFY THAT IN TISE PERFORMANCE OF Fort WORK FOR WIIICII <br /> TIFI 11A4[T IS ISSVEO,ISHAI;NOTEMPLOYPENBON■SVBI[CT 701NOR1OMAN'4 COMPSNSATION UWS OF C/LLEORNfA;CONTRACTOR'S IIIIYNO OR SVBCOMRACT1H0 OlONAT VRE CEITfER9 <br /> 11E PIIDVAHO: •L Cl RTIFY THAT M TIK PETITS MICE OF 114E O=AK V/IRCII l IMS PEItllR IS I!luED.F SHALL EMPLOY PElISONS 1VGJECT iO WORRWIAN'S COMP[NSATION TAWS Of <br /> GM pPMA.- ANT MUST CA11 S4 [N ADVANCE FOR All RFOIlRIp/MSPECIION■AF��IJOS1//'N'//J/LYL//,��I//]yys,�JG/O,�,MRETE ORAWIHO AT IOWfFR AREA fT0 [O. <br /> ryOT FI-AN R]•.w 1.SaWi B..I. Lo U <br /> 1.NAMES OfSTREETG OR MAO$NEAREST TO OR EOUNDINO 711E 4mmortTY. 4.LOCATION PF IOPlE SEWAGE MSPOBAL SYSTEM OR ROIbSED <br /> 7.OUTLINE OF 711E PROPERTY,OIVNNL DIMFNSOITS AND NOl"N OITECI,ON. EXPANSION OF SEWAOE OISPOGAL SYR EMB. <br /> J.DIMFMSMNEO OPTL .g AND LOCAl1ON OF ALL EXISS IRO AND PRIOMS[G ■.LOCA,ON OF WILLS WITHIN RApR1S OF ONE NWN7REO FIFTY FT, <br /> 111WCTURES,INCLUDING COVERED AMEAS i11U1CH AS►AIDS,ORVEIVAYS,AHp WALRRi. ON TIRE PTOPERTYORADJOINbp FFOPERTy. <br /> i .. <br /> 3 <br /> \ Pm <br /> " <br /> DAIMTMENT Vol OMT <br /> AOAA..II�.A..�Iwl BY6 <br /> D.1. 7-/ 1, `Y <br /> O:ou ImPr11e4 Ar� .. D.L /Fume Fnla.cll.n GY O.b <br /> C.�...: <br /> � <br /> -------------- <br /> ACCOLMI1111-ONLY. AIRF FAC! , <br /> FE CDOEI F[E;INFO AMOUNT REMITTFt. CRKC MASA /IECENED■Y DAEE VIERMITMERVICE REOVEST NUMS01 INVOICE <br /> 3s0Ii �i ca a <br /> Pub.FteaM Sm.-EmIro.173(1197) <br />