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532 ()3(./ - (J(/C/-s .5 <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> IIOA•REFBRBABLE PERMIT EXPIRE!1 YEAR FROM BATE ISSUED <br /> ICsmplsts In 71�11FstM1 <br /> APPLICATION 19 HERE BY MADE TO THE BAN JOADKAN COUNTY FOR A PERMIT TO CONSTRUCT A"MA INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MATTE IN COMPLIANCE WITH SAN <br /> JOAOVM COUNTY DEVELOPMENT <br /> /TRIS•CHAPTER <br /> � 9-1115.7 AND�111�7 OF SAN JOAQUIN COUNTYPUBLICHEALT"-SERVICERPNNRONMENTAL HEALTH DIVISION. <br /> ADDAEBSIOR APNF �0[ TJ PARCELeIZE1AfNF /� <br /> I <br /> OWNEAS NAME _ P,e' Wl <br /> L_PX1-J ADDRESS (J !��? �/�.� z PHONE IF <br /> CONTRACTOR (_,ills dr4��(.�iI�G��f Q.OFie� AOOAEBa1.L1e.Llx 39a �11t>";,-- <br /> !�*�i+IJC.7✓ FHONEl o <br /> austowAACTOI i 7 fir. AIIPREsa ✓! <br /> Lie 5 <br /> TYPE OF WELLIFKJMP. ❑NEW WELL ❑REPLACEMENT WEL! pp MONRORINO YVEit! ❑OTHER <br /> ❑INSTALLATION ❑WELL BYatEM REPAIR /❑CROSaLONNECT AEPAN Q VAPOR EKTMCTION WVFLL! J <br /> ❑N—❑P,.* H.P. DEPTH pUmv SET FT, FIRST WATER LEVEL O <br /> IT TPE OF PUMP) <br /> ' 1 ❑OUT-0FSERVIOE WELL ❑DEOP/IH((Y6ICIK vYELLF �Y.SE 600.BORMO �� 11 y <br /> ❑oEeTRucrroN1rtpyiysf !N�ltt ,fyS-x -e Cf�flJ �J ;fLIx:INv' fJiC l�f.��CCNr c< � F i i� <br /> INTENDED US F T P OP W CON/TRUC7ION SPECIFICA" / d <br /> ❑INDUSTRIAL ���❑OPEN BOTTOM DIA.OF WELL EXCAVATION MA.OF CONOUCTOR CASWO D <br /> Ll <br /> ❑PUSUC/MUNKIPAIE Jekk N PACKMIIE. TYPE bF CA <br /> ��SEAL � OSIA,OF I ON LL AGING <br /> .y❑IRRNIOA7gNlAO D OTNER GROUT SEAL INET I--�V �i(`[ 01bUf bMND NAME <br /> pl MOWIGGI G GROUT SEAL RIMI4D:lJ Yr CONCRETF PFOESTAL RY ORBI_E-'�mYN [IN. <br /> S <br /> APPIIOx,OFDTH LOCKMG CHESTER Bo%reiOVE PIPE O N 5,0A0,47 <br /> PIIOFOSTL CO TION1bmLLNO MEtHOb:MUD FIOtART' AIR ROTARY AUGER CABLE OTHER� <br /> 1"I COY CERTIFY THAT I HAW PREPARED TITS APPLICATION AND THAT THE WORK WILL BF DONE N ACCORDANCE WRN SAN JOAPUIN COUNTY ORDINANCES.STATE LAWS,ANO RVIEb ANO ` <br /> MOVLATtGNO IF <br /> OF THE SAN JOAGIM COtNTTY,HOME OWNER OR LICENBEO ASENT'S SMHATURE CERTIFIER THE FOLLOWING:'I CEFRY THAT M PE <br /> THE RFORMANCE OF THE MONK TOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMMOAFION LAWS OF CALIFORNIA.'COW KACTOR'S FINNO OR BVBLDNTRACTMO SIGNATURE CERTIFIES <br /> TINE FOLLOWOM: •I CERTIFY THAT N THE PERFORMANCE OF THE WDRK FOR WITCH TP1a PERMIT M MOVED.1 MALL EMPLOY PERSONO SUBJECT TO WOPIMAN'S COMPENSATION UYYa OF <br /> CAVFORMA.' TINE AM T C x+HOURS BI ADVANCE FOR Al).REOIRRED SFECTgNa AT 1706!SNIti126P <br /> .COMPLETE DIiAVWIFIO AT LOWER AREA FMVOEb. ! <br /> TIB. �ffi�^+'G���� �r- Lei <br /> PLOT PUN 91—T.ScW.1 S..I. N 1 eve--� A <br /> 1.NAMES OP 97REEF9 OR ROADS NEAREST TO OR BOUNOIHO"IE PnOFSRTY. 0.LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 7.OtRLME OF THE PROPERTY.OMM WMENSIONO AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL aYOTEM0, <br /> ].DMENSIOMEo oWUW.S AND LOCATIONSTN <br /> OF ALL EXIG AND PROPOSED S. ION 11F WELLS LGCATWITION PAWS OF ONE HUNDRED FIFTY FI. <br /> S7RVCTVREB,MCLIIMNO COVERED AREAE SUCH AB PATroB,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROFERTY. <br /> : <br /> v�/~fi . `z� sir t } P <br /> E� AYMEN ° <br /> MAY 2 <br /> p. <br /> X�O . <br /> : <br /> SAN agaqulNCOUNTY <br /> __ ....: .. :PUnLJC HEALTH SERVICES `. <br /> ENVIHC NME4TAt HCALTH D(VISICN <br /> ...... ..... ............. .... .................. ............. <br /> OEPMTMENT USE ONLY <br /> ai <br /> ARpll.nl.n ANwMH•d 9Y D•I. �7 � �� h.. <br /> G��7LJ�D�JRDF�7YG= 3—K�rl-r..' <br /> G�.u1 tr..I•n BT 'p 1 t,tsW�+S O•T. MIP h.—d.n aY D•N <br /> oe.ul�n•o Ir•P.�Ilen Rr 7/1eJ�c-+�C�.g JOA�7^El� 6,3/48 D.,. <br /> S J28148- rf rq r'w e(d J <wIs{� �. l� r �.Js¢. w seat o• co,(e !b <br /> C Ir. <br /> el1� --,y 'T d' �: ..m YvD1(q 2—Ta's Y17o Ne:�J o use�e r� 00 <br /> AccOVNiHNO aNLY: AUDI FAC! � Q�� f��)tiv <br /> PE CODES TEE INFO ANOINT AOAtTttb CHEC ICAIN I REc7TVE6 BY DATE F6FAITRERVICE REQUEST NUMBER INVOICE <br /> T,001511 7P.,h W—RI,RAnI-Fnvirn.177 f11R75 <br />