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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 0 <br /> P 0 BOX 388,445 N.SAN JBAQUIN ST,STOCKTON,CA 85101.388 <br /> 12091468-3420 <br /> NON-REFUROARLE PERMIT EXPIRES E YEAR ROM VAI 133000 <br /> IC4Np1Et•IS TrVFWvNiI <br /> APPLICATION M HERE SY MADE TO TETE BAN JOACHIN COUNTY FORA PFNVAH TO CONITRMT ANONRINSTALL THE MM DEWC .TMS APPLICATOON 1S MADE M COMiIRAHCE WITH SAN <br /> t` JOAWIN COUN"DEVEIDPJENTMTIF.CHAFTFA 9-111 b,3 AND THE STANDARDS OF SAN JOAOUOJ COUNTY PUMJC HEALTH WIVICE$.OMMOFMENTK HTALTH DN MOM. <br /> Joe AOOAE6SIOR APNP 2%Mo VLQELF IQ\SE %,,11 erry I Qq CV Cti _PAMM VrWAPH• <br /> owNEn-e NAME_�00.o1^V-Ly l:-IFat_C� PnanEEs LAEE mahl -a,I�CS.^innr..TR FHoNEFI�$ 5-47{5 <br /> CGNTHACTGA^W2\G4iT ADDI*89 Neto COMTncana 1�2°LS Lle•LS'ISdI rREONE E(r-cril 1333-c,75& <br /> F ftA l'fa gs3gL <br /> Eve caNrnAcron {G��L\aAV Cx \A]4LL,,�?�>L<Zt nlG AooREs• tlG•482390 PHONE !E: R;'-K.b13 <br /> TWE OF WTll mV ,, ❑NEW WELL ❑MPACEMEw WELL ❑MOMTOAHO WELL E O OTNEl1 <br /> ❑INRg <br /> ALLATN ❑wELL SYBTEM REPNR ElL CROem "BCT PEPAN ❑VRwn EITnACTIDH WELL f J <br /> O N-13 R.•.N N.P. DEPT"Pump EET_FE. Fmr WATER LEKL O <br /> (TYPE OF MAA iJ�y E--I 073E-0FBFRYICE WELL ❑GLOPHYMLK MULLES v�EOI�eOR BORRO ! <br /> ❑OESTM=10M <br /> AMMIlm UFE TYFEOPTARE yONSTRMTION IPECMCAT1ONS A <br /> ❑SIDUSTRAL, ❑OPEN BOTTOM DIA.OF WELL EXCAVATbn DIA Of CONDUCTOR CAMNO D <br /> ❑DOMETMPIIVATE ❑GRAVEL PAaU n TYPE OF CAMNORTEEL/PYC VIA.Of WELL CASMD 0 <br /> 0I-S P WCAWNICIPK ❑DRVEH DEPTH OF GROUT"A& SPECRICANION A <br /> IWGATIGNIA0 ❑OTHER GROUT SEAL MSTAUFD OY O1S]UT RKARM NAMEF <br /> 11--'11 <br /> 13MONRTORINO GROUT SCAL MU MK-- 11N. OaNCR><TF PEOFRK SY ORMlf1E❑Y. T,J Nn T <br /> APPROII GETTER , F�E� LOCK>MO CNEVER SOR1eTOW AK T� a <br /> PROPOSED GONETRUCTEONJMSWNO METHOD:MUD ROTARY NR ROTARY SS <br /> AUGER CAE OT1ER7 UQf CS R-'-E{ <br /> 1 HERESY CERTIFY THAT I NAVE PIIEPARD THIS ADPLICATWN ANO THAT THE WOR:WRL BE DONE N ACCOAOANCE WTN SAN JOAOVIN COUNTY ORDINANCES.STATE LAM.AJN RULES N10 <br /> REGULATIONS OF THE SAN JOAWIN COUNT'!.HOME OWNER OR MINBED AGENT'S MOMATURE CHTRIES THE FOLMRMPIO:T CERTIFY THAT M THE PEIFORr7ANCE OF THE MRK FOR WHICH <br /> THISPEAMLT12I9SUED,FM4A" OTUM OYKPAONESVWfCTTOWORMMAN'SCOmmeAgNU1MISOECµ7om*A.,CONTRACTOMSHIENOORSUS-COMRACT/i mNATURECIMMIFS <br /> THE FOLLRWOIO: •1 CE/TWY THAT M THE POFGR ff OF THE VMAK FOR WHICH TMS PERWT IS 1•SUEO,I WALL MKOY PERSONS SUBJECT TO WOIUSIAMM COMPENSATION LAWS OF <br /> CALIFOlERA' IR ADVANCE PoR ALL RAOVIIIED 1NSMCMNI AT I2M1 aA 27.COMPLETE ORMWNO AT LOWER AMA PROVIDED. <br /> N ! <br /> _�_. RT.OT PLAN IOrwV I+MNH s.r. I •[• X33 <br /> 1.HAME9 OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERYY. A.LOCATION OP HOUSE SEWAGE McPo$AL"WEM On P M9EO <br /> S.O NE OF THE RROPEJTTY,OIVING OIMEMMONS ANO mRrH DIRECTION. EAPANMON OF SEWAGE O/EPOSAL SYSTEM•. <br /> O-OIMENEIOHm OIIHMES ANO LOCATION OF ALL EXH TDIO ANO PMPOREO E.LOCATCM OF WELLS WTHNI NAM"Of ONE MR{MEO FM1T!Ff. <br /> WTN1 URFI.INCEVOM COVERED AREA$SUCH AS PAT;OE,DRIVEWAYS,Mn WAULS. ON TIES PROPERTY OR AOMMM PROPERTY, <br /> a • 'p <br /> L9 <br /> - I9 <br /> -.. TankE17-D <br /> ® s....i.. .. ;. <br /> Tank 2 <br /> Hanger -Area <br /> Fon.TmkLGctlan <br /> t <br /> 1 Pi opined BGrtng LDeatlan <br /> Pescadero <br /> OVARTMBET LIEF OFLT G <br /> AA•ePwl•n A. 0d• S V ! A,. <br /> hu+t Hw••rrw GT IMn 1'uII•I•f•FOUI h O•u <br /> OrRYSU•n VURn•II•n RF hR <br /> Ci•RI�IIS: <br /> ACCOUNTING ONLY: Am+ FAc/ <br /> K COOu FR UGb --T-.- RSCISVEO ET DATE FORAM -MCI RSWIST IIIBPSAR INVOICE <br /> ro/ <br />