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APPLICATION FOR WELLIPUMP PERMIT <br /> .AN JOAOUIN COUNTY PUBLIC HEALTH SERVR,-:_ PAYMENT <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, W4 EAST WEBER AVENUE. STOCKTON. CA SMI-3118 RECEIVE[? <br /> (209) 488.3420 FEB o <br /> NON-REFUNOARLE PER Yrt PEPiRn I FROM DATE ISSUED PUBLIC <br /> SLI <br /> ENVIRO Cl-r;., <br /> Et <br /> URICATIOH 18N Y DE EL MADE TO THE MN JOA COUNTY FOR A PERMIT TO CON{tRUCT ANDIOR MRALL THE WOFK D[SCNBED.THIS ATEICATIDN q MADE M <br /> MAOVIM COUNTY pEVFLOPMENr TRLE.CHAPTER f- 115.3 AND THE lrANDAFDS OF JOAQUIN 2l� COUNTYkMlEAF�EneToI�AEN <br /> 3L � FfU,I,UC NFALTH aFRV C(E.[ltV 11DNMENf/i HEALTH OMNOX. <br /> AB ADpI[SS.On ARI — 5��_)•)ll�C..ln tom\ PARCEL SMA~ <br /> OMMIITI NAMF ADDII[SS R_11(1'101-F./ LC <br /> nt; �nl 11 PHONE <br /> coNRRACT nb Vo v UCE PH <br /> NE is <br /> "CoNrRACTOn kva4 <br /> - <br /> I tin Ls.. Yc s'r <br /> �/ ADO^EM LJCJ 5 54979 NIONE � G 6• 2�4 <br /> •YPE OF wEl1,wMF' D PIEw WELL ❑ EMENr WELL 1D�MONRORlw WELL F /.+.11. LSI. D OTHER <br /> ❑ MSTALLATION ❑ L <br /> 1OPA111 LJ, Cbtb{ONNR VAOR EJRMCTgNWFLiIN.P• II.P�rDERV RUMP WT�Fr. fI11S7 WATFP LEVELTYPE OF RUMP ❑ E WTII D OEOFHYMCAL w2LL P ❑ {Oa/OMP e <br /> J DE{TRUC'TRDN: <br /> YIFNDm WE Y OF W CONSTRUCTION SPECIRCA ONE � <br /> NDUSTNµ ❑OPEN BOTTOM " A <br /> dA OF WELL EKCAVATgN dI�OF CONDUCTOR CAVING p <br /> I DOMESTICUPRVATE ❑OMVEL PACKI{QE TYPE Of CABINO/{TEEL/WC Ir <br /> DIA.OF WELL CABiIq D <br /> 7PVBLIC/MUNKRAL ❑dSVEN DEPTH OF amuEEµ O — 's SPEDIFICATIO <br /> :a3 PIRIGATIONIAO ❑OTHER GROUT RAL INN ITALLED BY ( 0/ OROIR BAND MARIE P <br /> .I MOMTOPNO �J OPOUT KALI`Uwv[D: DY. <br /> .PDIH E COMCRFT[LEDERµK DRILLER:D Y� DNe S <br /> EPOK'DEPTH �'- �� LOCKING CNERER BOxwow FRE <br /> J <br /> POFOSm CONiTRU-TK N1dSWM0 FAETIgD: MUD(1DTAl1Y AIR IIDTMY AUOEIICABLE OTHER <br /> iFRSY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(I BE DONE IN ACCORDANCE WREN BAN JOAOUIN COLIHTY 011pNAHCto.RATE LAWS,AND,RULES AND <br /> !GVLATIONS OF THE SAN JOAOUIN COUNTY. NOME OWWR OR LICENSED AOEW'S MONATURE CEWIFIE{THE FOLLOWII10: <br /> Mt •I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WMCH <br /> FODLLOOIR P ISSUED.1 tHALL NOT EMPLOY PERBOMS SUBJECT TO WDIRIpRAI'S CWFBHITON LAWS OF Cµ RHEA-• COHTMCTOR'S NFNNO OR B ONTRACTI D SIpNATURE C[ITRES <br /> -R WING: I CERTIFY THAT IN THE PERFORMANCE OF THE VAW FOR WHICH TILS PERMIT IS ISSUED,t SHALL EMPLOY PEREOM SUBJECT TO WOP ",IE COA/IlISATOI Uwe OF <br /> WFORMA• / APRUCANT MUST CALL GA NOW IN ADVANCE IOP ALL RE PKTIO I AT 1 1 ASS-/125. COMPLETE ORAWtHO AT LOWER AREA IMVIDEO, <br /> •� <br /> P•.E K TIM / Ow. ' ( I O <br /> RDT S.WI BP.I. •ro LN <br /> XAMES OF rrnm OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, A. LOCATION OF HOVK SEWAGE PWSµSYSTEM OR FPpFORD <br /> OUTUNE OF THE PROPERTY,GIVINO DIMENSIONS AND NORTH dPECTMN. EKPANSOk f S M* w^oj"llpoDL SYRMS. <br /> D'MENIPONED OUTLIES AND LOCATION OF ALL Ex18TINO AND NR IMMRD {. LOCATION OF W[lU WITHIN RAGAS r ONE NVHDIOD FIFTY IT. <br /> STRUCTVI[S,INCLUDING COVERED AREAS BUCN At PATIOS,DRIVEWAY{,ANp WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ......:.. ... .... .....!. ._o-....: <br /> - .;._ ......?. .......9.....:.....4......x.....n <br /> ....:.....:.... .....y.... <br /> .n :..._n.....�.....o ... .. <br /> ... a.. .:....Y.....�....P...._ <br /> A V. <br /> -_.......... _.... ..... r, � ' <br /> .......a.....: <br /> ............4......:.....4............' f _ <br /> 4......�......a...... /w' <br /> .... ...... .....O.... �f ..... .......... <br /> ....:......n.............r......t.-....0......:......�......:.-....4•.....¢......1......1......• ...1..... <br /> f 1 <br /> DEPARTMENT WE ONLY <br /> ""'°^"'FRN"a Dn• � s P6 AR. F�P ,v�N1�a\J <br /> .•IJ PPI..INn <br /> By Dn• Run I,�PP.IP,a S1 On. •�Ta <br /> �•uWn tr...H>M by Mu <br /> .M... 9ly —�Z/—CL ,�..ue.c— • �1/il/5 /D, // f /Z <br /> ACCOUNT1.10 ONLY: AD/ FACE <br /> R COD4 FR IMFO AMOUNT Rp4WTTm C"Irciux"kll_� Li u <br /> RECEIVED BY DATE POIMITM VID{iROUNIT NURIll/I INVOIC{ <br /> 350 t z z fG Oo8 03 <br /> ' d b i Poi i 020 Wpd� <br />