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APPLIC*AWON FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> WAMP141E iR Tlblk/E/1 <br /> JOAQUIN <br /> COUNTY <br /> NEVE EL MADE TO THE SAN JOA WIN COUNTY FOR A PERMIT TO CONeTRLICT ANDFDR INSTALL TIIE WOR(DESCRIBE(),TINS APPLICATMN 19 MACE IN COMPLIANCE WTTII SAN <br /> JOAOUIN COUNTY DEVELOPAEM TITLE.CHAPTER 9-11}6,3 AND THE STAJN1DARDS OF RAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMEWAL HEALTH()RRSION. <br /> JOS ADO11E8SIOR APNI ` 1 1[ Re 5' LI 1 �AL�'1 �/ SSSlll <br /> 1 <br /> CITY PARCEL SI2EfA/E11 <br /> OWNERNAME \fA< R`T ^- <br /> AdRtERe h PRONE <br /> CONTRACTORC 4)-4 LtJLAe.f <br /> -- --�S,F�'_-Tp•_ - V •(� ` O I4iiCCKJiLAOM.RR C2U - d . aMIT <br /> RVR COMMCTOR 1 O. <br /> y <br /> LACS PHONE 3��' 7, t'.I,3 <br /> TYRE OF WTLL"mr; Q NEW WELL ❑VEPLACEMENt wEtL ❑MOPMONN(I WELL S ❑OTHER <br /> ❑INSTALLATION ❑WELL SYOTFM REPAIR ❑CRORS-CONNFCT REPAIR ❑VAPOR FXTRACTRIN WELL/ <br /> 11 J <br /> N..v❑PM11SI. N.P. RF.fRH PV MP SET n, <br /> BYTE OF PUMPI �_ 1`LTyIIRST WATER LEVEL O <br /> 11OU7-OROF WELL ❑GEOPHYSICAL WELL L,{I RAIL PONNO <br /> 13 DESTRUCTION. <br /> �L B <br /> INTENDED USE TYPE OF WELL CONSTRVCII011/PEIFICATION/ <br /> ❑INWSTRIAL ❑OPENNOTTOM A <br /> VIA.OF WELL EXCAVATION DIA.OF CONbL1CTOR CASINO O <br /> ❑DOMERTICAE/VATE ❑ORAVEL PACKMZE TYPE OF CARINnMTEEl/T°C VIA.OF WELL CASINO <br /> O <br /> R/SLICMVMCIPAI ❑DISVEN pF,P•TH OF Ol10UT SEAL SPECIFICATION <br /> ❑MRIOATION/AG ,!'.pT R R <br /> CvhTIPFh0. �C•.}"\srJ i I by rI'm 95 ORDUT BFAG INSTALLED BY GROW BRAND NAMF F <br /> ❑MONIlONNO /'� Or`rRn REAL PIMPED;11Y.. [IN. CONCRETE IVDE13TAL BY DRILLER:❑Ym ❑Ne S <br /> A►PRO R.DET.TH .3`!• � LOCKING CHFRTER RO%RROVE APE <br /> 5 <br /> PIOPOSEO CORSTRVCiroNPDIEttMO METHOD: Mw ROTARY AIR ROTARY AUGER CARLE OTHER <br /> I HE'/Y CERTIFY THAT I HAVF PREPARED THIS APPMATION AND THAT THE—'—WILL SE BONE IN ACCORDANCE WITH/AN JOAQUIN COUNTY OROINANCE,.STATE LAWe,AND RULE,ANO <br /> REOULATNNIS OF THE RAN JOAQUIN COUNTY,HOME OWNER OR HCENf l)AnENT'S RIONATURE CEHTIFIFS THE FOLLOWINn;•1 CERTIFY THAT W THE PERFORMANCE OF INE WOR(FOR WHKH <br /> TMS PERMIT IS 1SSVE 0,1 BIIALL NOT EMPLOY PERMNS RMJECT TO WORKMAN'S COMPPNSArIaR LAwj;OF CAI-WOMA.•COMPACTOR'S HBOHO OR SUB COMMC7RIO SIGNATURE CElRKIES <br /> THE FDLLOWRIO: 1 CERTIFY THAT IFI THE PERFORMANCE OF THE WORN FOR WHICH TERR PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORRMAN•f COMPOIfATIOM UWS OF <br /> GMIFORNIA" THEA FIT MUST CALL RS HOURS IN ADVANCL FOR ALL REoUS1rn MSPF!rKI NNNS AT 1)0111 409 24,l�.l�.L COMIZETE OMWOq AT LOWER AREA PRO COMPI NS <br /> SIO..RS R--. I ' �'C)I"" \I S�� O <br /> 1IO1 FIA.IO.R••1.9e4.1 Re1. to <br /> t. IKEMS. <br /> NAMES OF StAFETS OR ROADS RFARERT TO bR BOUO NOINTHE pnor*Rry. 4.LOCATOF HOUSE SEWAGE dBPOSAI SYHTEM On A101pgED <br /> 2.OUTLINE OF TIIE PIOPERry,(IMMKI OWENSIONS AND NORTH OWCTIvN, ERPANSOOF SEWAGE dSPOSAL SYST <br /> ].DONICHMNFD OUTUNO TS ANLOCATION OF ALL ERbTm AND PEOPOSFO S.LOCATION OF WELLS WITHIN MDR// T ONE MUNtmED FIFTY FT. <br /> STRTUIES,SICII/OPNO COVER()AREAS SUCH AS PATIOS, ANb WADI S. ON THE PROPERTY OR AbJOmm PgPERTY, <br /> - <br /> - <br /> ft <br /> • 2 l a.a.rl <br /> '1Tn �jaf thg <br /> f <br /> ham.- f r Coto <br /> N T <br /> .SCA L'E <br /> I <br /> 1)"ARTMFNT USE ONLY <br /> ASPM-0-A—Id <br /> Mw <br /> p.euR Y,.R.e,lo..er t.���SLA.\F•r�� o.,. '� �/ P..,P LnPaclleR Br o.,. <br /> Dw.,netNn IrNR.ctbe BR O.I. <br /> Ce <br /> ACCOI/11TIN0 ONLT; AID/ FAC/ <br /> ►f CODES FEE INFO AMOUNT RONIT7 ED CIIECkIICASH F11r. D■Y ()ATE ►NMT//()INCE REQUEST NUOS9E INVOICE <br /> o Roo sYiz Z z a <br />