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APPLICATION FOR WELL/PUMP PERMIT <br /> f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 9S202 <br /> (209)468-3420 <br /> NON-REFUNDABLE_PERMIT UPI"I I YEAR FROM PATE ISSUED <br /> {CBIRpI$t$IM Te�Si$RBI " <br /> APPLICATION IS HERE RV MAIM TO THE SAN JOAOIAN COUNTY FOR A PERIM TO CONSTRUCT AWFIOR INSTALL THE INOW D£BCRIBEO.THIS AMICAT10k IS MADE IH COMPLIANCE WRIT BAH <br /> JOAOVIN COVTNY DE'VELOPAIIENT TTRm CHAPm 9•1 115.3 ANC TM STANDARDS OF SAN JOAWAN COUNTY PUBM HEALTH SERVICES,ENVIRONMENTAL HEALTH OIVIs10N. <br /> JOS AODRES18MR APTU -?� 4F-{E'--C_ •4' r �+.1 ..� ( JL [� _CITY 4•-( [.I l PARCEL WMAPNI <br /> OWNER'$ i�NAME n i '� ' L4 ADDRESS/"" r f' PHONE#.4 <br /> CONTRACTOR 4 1 L L. ADDRESS e�� 1C..L61t.1r4�1 J'Y� T� AIOHE I�� •,. <br /> SUBCOMRUICTOR - ADDRESSr!/ (fC1_J71Y . .PNONE• <br /> TYPEOF WELiiP_OMP: ❑ NEW WELL ❑mnACtmm WELL ❑ MONITOWNO WELL P ❑OTHER `'� <br /> ❑i"ffiATNIN ELL ST <br /> ❑WSYEM REPAIR CI cmes-CONNECT REPABI 13 ELL VArm E%TRAcnom W • J <br /> C}N. E3 mm.0 H.P. of PTH PVMP SET TT. FIRST WATER LEVEL D <br /> n YPE OF PDMP1. <br /> - 0 ow-or-SERVICE WELL ❑acommSICAL WELL♦ 13 BOIL Some e <br /> ❑DfSTWDCTMN: <br />!! E CONsTRUC Manng �} // A <br /> Ld INDUBTWAL El OPEN sorre 1 DIA.OF WELL EXCAVATION DIA.OF CONCOCTOR CASINO <br /> 0 OOMESTICM110VATE GRAVEL PACKMME TYPE OF CASMIGISTEEUPVC 04A.OF WELL CASINO D <br /> ❑FVBLICIRRN KwAL []DRIVEN DEPTH OF amtrr SEA[ SPECIFICATION <br /> ❑ SSSGATIONIAG ❑OTHER GROUT SEAL INSTAUXO SV ORO1R BRAND NAfum tc-t <br /> Q LLDTBTOrmn jj f TL amw SEAL.T jmKo:E3 <br /> Y. ❑H. CONCRETE PEDESTAL 8 DMLUR:C}Vr ❑N. s <br /> AMMON.OEP'PH. ��4.;'[� i ` LOCK010 CHESTER BOXMTOVE PIPE s <br /> IMPOSED CONS TTILICTRONfORILUNII NUMDI NUC IOTATLI/ AIR ROTARY ALINES CABLE OTHER <br /> 1 HEVEBY CERTIFY THAT 1 NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE CONE IN ACCORDANCE WITH SAN JOAOUtN COUNTY ORDINANCES.STATE LAW$,AND RULES AND <br /> I TimaAmwe OF THE SAN JO�Amp COIARY. HOME OWNER an LICENSED AGENT'S SMNATUIE CERTIFIES THE FOLLOWM,.'I CERTIFY THAT IN THE PEIWDIWANCE OF THE WORK FOR WHICH <br /> TISS PENINS IBI 1 _ MOOR BUWFCT TO 10110R1KMAWS CO#RPENSATION LAWS OF CAUFORMNIA.' CONTRACTOMB HIlWM OR on-caNTRACTWO SIGNATURE CERTIFIER <br /> THE Wll C SN A THE ANCE OF THE WOW FOR WHICH THIS PET"T IS ISIRRO.T SHALL EMPLOY PERSONS SUBJECT TO VHMWAWB COARI DATION LAWS OF <br /> CALIFOIMIFA." �T MY$ C HO IN ADVAMCIE FOR ALL Tgi4U1RW p1B►[CTIOMS AT 120��{$$�SA RETE AT LOWER AICA PROVIDED. <br /> N r <br /> 0 <br /> X/ TRI. <br /> k r <br />' - "APT FLAN phew to SnoW Seal.-,1. <br /> M 1.TAME$OF STRUTS OR ROADS NEAREST TO OR BOUMM THE PPOPERM 4. LOCATION OF}{OUSE SEWAG$DISPOSAL SYSTEM OR PM I;go <br />' I.OUTLINE OF THE FRI NVMY,OPANG DOMWOMMS ANC NORTH DNECTION. MANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 7.ONRIIENSIORIEO OlIfUMS ANO LOCATION OF ALL EID6TIH0 AHD PROPaSED S. LOCATION OF WELLS WRHM TIAORIS of ONE"UNOWD FIFTY PT. <br /> STIBRCnWS.IRCUMM COVOW AREAS SVC"AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY Out ADJOMBTNR 10111DPEMY. <br /> 5 <br /> .... . <br /> jl� <br /> AYM <br /> � f I <br /> fa? J <br /> OCT 2 6 1998. <br /> .. . , . :... ... .... .._,.... 1 <br /> �.f.f.. . �._ �.. '. <br />