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APPLICATION FOR WELLIPUMP PERMIT 0 0' 3-5 <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES 00 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N. SAN JOAQUIN ST.,STOCKTON,CA 95201388 . <br /> (209) 4883420 <br /> NONAEFUNDABLE PERMIT WINES 1 YEAR FROM DATE ISSUED 1 <br /> IGNpMBi In Trip usul <br /> MflICATION IB XNE OY MADE TO THE EA'JOAQUIN COUNTY FOR A FORMIT TO CONSTFUJ T ANOroX INSTALL THE N dACWOED.THIS APP.ICATION R MADE W COMMANCE MH BAN <br /> JOAOUM COUNTY DEVELOP%ic–T-LNI,E,CHAP/T�ER9-T1113{.3 AND THE STMDAPDOOFppAN JOAOUIN COUNNTY RI&1C HEALTH UNW ES,EN NMEMAL IEAEM GNOgN. <br /> Jon ADDRESWOIIAMA E'yS7U L T/OFIGi- �Ly<O( cm ACG. iii PA ELSuiuxe <br /> �J Z. <br /> GwxBR'a NAME I)Na l/P Yrrry ADORES (iS'/U `-. rca k>N I' PIr NEF 23`j-g3CJE <br /> coxrrucroN /� QO/.SLS 1nl c.{r- S�.c hr+ S ADDRESS Z/7U T�Ji1L rr ucr Y6 YYi,(a PxorvEA 931-3..T/L <br /> SUScoNMACTOX MiI �(_ I�v ADDI /19 hL/g frS LIc LZ INOK,Szz-)q <br /> TTPFOFATUn P: A NEW'WNL ❑M EMEM WELL ❑MONITORING WELLY ❑ OTHER <br /> ❑ INSrA�UATNIN [IIwU SYSrEA XEpAR ❑CMS..NNE�CTT(S�EPA111 ❑ V.AE%TT TION WELL/ J <br /> Sub fyqL N— RRin, N.A.�flb DEV NPUMV 9ET(_L FIRST WATER ur O <br /> mR of RDF <br /> ❑DUraF-sERVICE wELL ❑ DEORrceICAL WTlLR ❑ adL NCwrvo s <br /> ❑DEETIMMON: <br /> INTEMOM USF TYPE OF ABU CONSTI ION SPECIFICATIONS , A <br /> ❑ SDUSTWAL CI OPEN MITTOM dA,OF WEU-EXCAVATION 1 N OIA OF CONDUCTORCABINO O <br /> ❑DOMESTIC7WVATE A.a DRAWL PAOJN" TYPE OF CASINGISTEL/AK QUG DIA.OF WELL CASINO O <br /> ❑Ms,x uN IPAL 11 E. DEPTH OF GPoIR BELL CSI UECIPICATMHIr� A <br /> UUU.ATFE.'AU MOTHER GROUT SAL INSTAUM sY M u S r 11''' — GROUT BnAND NAME E <br /> ❑MONNONN. GROUT SEAL FLUTED:®Y. ❑N. CONCRETEFEOESTALSYINLIMOYSS 03N. s <br /> APTGF.ONSTIR ZOOT LOCKING CHESTER BOXWOVE M S <br /> PROMImCONSTRKTIOXDNWMO MR1b0; MUD Mi I," AIR ROTARY AUGER CAXIF OTHEN <br /> I HERESY CERTIFY THAT 1 HAVE ENPAMD THIS AFRICATMN ANO MAT THE WdN WILL BE CONE IN ACCORDANCE WITH SAN.pAOUIN COUMV ORDINANCES,STATE LAWO,AMO Mae AND <br /> NEGUUTIONS OF THE SAN JOAWIN COUNTY. MME OWNER 011 UC MUD AOEUT'S SIGNAMM CERTIFIES THE rOUOW WO:'I CEFTIFV THAT W TME R1fOPMANCE OF THE'NOW MR`M4" <br /> THIS PEWAR IS IMUEO,IMIAU NOT INFAMY RRSONa SUUECT TO WORKAAN'S cwAMSATOM NWS OFCAIIFOMA.- C.NMCTOR'S...OR a ONTMCTIM SIGNATURE CERTIFIES <br /> ME MLLOINM: -1 CERTIFY THAT IN THE FERORM.WCL OF THE ARM FOR WNCH THIS PEMET R ISSUED,IMN MUR_OY PERSONS SUSWECT TO WOIIWMY CONUMBATpx UWS Of <br /> CAUMRIIA.' TI APPIMYIT MUST CLLL]S MUD IN AOVANCF NOR.0 Ann.IR/Sp$g��TM1XS AT MX,II 401134]l. CWARFTE pUW WG AT(OWER AREA HANDED. p / <br /> MT.Idr'A",An.'s <br /> I.NAMES OF ST 11MADS NURST TO OR SOUNdM THE PROFEOY. A.LOCATION OF XOUSF ifWK.E daMSK SVSIFM OR R'OPoBFD <br /> ].OUTUHE DF TK YYFROMM,OMM DMESSRU S AND NORTH MIERKW. EXPANSION OF SENAOE dW9SAL SYSTEMS. <br /> 3.OS.IENMg 01RI AND MATON OF AM EXISTING AND PROMISED O. MCATMN OF WELL WRMN MpUa OF OFE HUNDRED FFTY FT. <br /> STRUCTURES,INCWDNO WWRID ARI WCH AS PATOS.DMYEWAVa,AND WNJ(B. ON THE FROM Y OR AD.DIMNG RDPFATY. <br /> k Tak +t /e �- <br /> G I 4Mc <br /> N ; <br /> N e > ..r '1 5f <br /> e . <br /> t (�arAl . . F1ow ir x <br /> eat. <br /> ....; i <br /> Q <br /> i. ..i1 <br /> 4 ItIN4,r . <br /> 9JfA.. ZDOE <br /> pU <br /> �ItA, mai <br /> 1� <br /> .. <br /> .... . <br /> AM111T .... <br /> �#� Et1f <br /> E� _ jL <br /> -e <br /> '4 <br /> .. . .... �4ax E'A?�'NPNh <br /> ?UFil.l(,11-'�f•?)ori.__ I I <br /> DD•Mm1ENT wI ONLY <br /> AcroUxrWo oxLr: AIDI FACE <br /> S GOOFS FEEIMo AMOUNT IIFT.YTTLD 'Ira/DAWN SKGVm YY DATE FGMTIYEWICE REOMT NUMS. 2,I_13 <br /> 0 O a <br /> $RD °3413 <br />