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APPLICATION FOR VVELL►PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> RO, BOX 388, 304 EAST WEBER AVENUE, STOCICTON, CA 95201388 <br /> 1209) 4683420 <br /> NON—REFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> (CBmpbt/In Triplie/tel <br /> AT".fr.ATION IR HERE BY MADE TOTHE BAN JOAOIJIN COUNTY FOR A T'f.RMIT TO CON STnUCT AND/on INSTAtL THF WORK DFRCnIREO.11119 AMLICATION IR MADE IN COMPLIANCE WIT11 SAN <br /> JOAOUIN COUNTY DEVELOPMENT ILTLE,C1IAPTEn 9.1 116.3 AND TIIF STANOAnon OF RAN JOAOUIN COUNTY,``MIRLIC IIF.ALTH RFFIV10ES.FNVIn0NMFNTAL IIEALTII DIVISION, <br /> JOB AnDRERO/On APN/\. �� ,�\ 1����_—_r_II Y `V�\ ` rAnCFL RIZFIAIM)I <br /> owNrn'R NAME LOc�i\ �1�m�1C\A\ �C'�h1c \oo` ADDnERR MIONF.1333 \a <br /> AnOnrBR �1 V.�_t`�IPc1\L\OLL IJC/ NfONIF <br /> 1�']�•mn <br /> RUB CONTRACTOR \� ADOnFSs LTC# MIONF 1 <br /> TYPE OF WELUPL1Mr: ❑ NFw Wrl1. ❑ nFPtACFMFNI Writ ❑ MONITOnIlIn WFII-1 ❑ or11Fn <br /> S�� ❑ MFT ,yr INRTAIIt ATION 11WFIL SVRI FM nFI•Aln ❑ Cnn RS-CONNFCI`nFrAln U VAMn EXTRACTION WELL 1 r <br /> IJt\ lN\ <br /> fi VrE Of T'VMPI New 1A1 Moir 11 r.�_ OEPT11 rUMr SFT. Tinny WATER LEVEL r O v <br /> ❑ ouvor SERVICE WELL ❑ OEOMIYSICAL WELL/ ❑ Roll.BOfVNO S <br /> ❑OESinI/CTION. J <br /> INIENbED VSE f YPE OF WELL CON/InVC)ION SPE6IFICA110N/ -- <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WTI I.EXCAVATION1�LT <br /> DIA,OF CONDUCTOR CASINO__ D (Ty <br /> E) DOMF9TIC"IVATE ❑GnAVFI.PACK/RIZf TYIE OF CASIHn/ST EFVPVC DIA.OF WELL CASINO r) \`A t <br /> �p❑1 MIRUCIMUMCIrAI. ❑nn1VEN DFPTII OF Onollf SEAT. SPFCIrICA110N — — S <br /> Ipl Innln All0NIA0 ❑OTIIEn GROUT SFAI.INSTAU FD BY GROAT BRAND NAME — F <br /> ❑ MnNITnnINO nn0UT REAL PIMPED! ❑Ye. (IN. CONCRETE PEDESTAL BV OnILLER!❑Ye. ❑Ne 5 <br /> APMIOX.DFPTII `USI LOCKING CIfFSTEn noxlnioVF MPF S <br /> MOrOSFD CONNTRUCTIOWDETRUNG METIIOV: M11D ROTAnV Aln nOTARY AUGFn CABLE OTHER C� <br /> 1 IIERFBY CFRTIrY THAT I RAVE PRF,rARED 70419 AMLICATION AND THAT THF WORL WILL OF DONE IN ACCOnDANCE WITH RAN JOAOIIIN COUNTY OROINANCER.STATE LAWS.AT RlllEB ANO `� <br /> RFGIILAilON9 OF TIIE RAN JOAOVIN COUNTY. NOME OWNFn On LICFNRFD AGENT'S RIGNATUnE CFn-FlFIEs TIFF FOLLOWING: '1 CERTIFY THAT IN TIFF PERFORMANCE Or TIIF.WOR(Fon WIIICI4 <br /> 11419 PERMIT IR ISBIIFO,I RIIAI L NOT EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS Or CALIFOnN1A.' CONTRACTOn'R TIMING On PUBCONTRACTINGSIGNATURE CERTIIIER <br /> TIIF FOLIOWINn: 'I CERTIFY THAT IN TIFF PEnrORMANCE Or TIIE Wom Ton WIiICH TATS 1EnMIT IR ISSUED.1 SHALL EMPLOY 1`ERRONR RIIRJFCT TO WORKMAN'/COMPENSATION TAWS OF <br /> CAI IFOM)IA.' TTHE APP ICAN`T MU/T CALL 24 NOIR/IN ADVANCCE FOR ALL AF.OURF.O INlPECTIONII AT 120014093423. COMPLEIE DRAWINO AT LOWEn AnFA MOVIDEO. <br /> NO <br /> Bt0rw1 X ` \�� �1 ��r Till. <br /> b.1 e <br /> PLOT PLAN(0—1.Rniw)R.:•Ie -1e <br /> 1. NAMF.B Or RTRFFTR On nOADB NEAREST TO On ROUNDING TIfE MIOrERTY. 4. LOCATION Or IIOIISF BFWAGE DISPOSAL SYRTFM On PTV)M SED <br /> 2. OUTLINE OF 711E PROPERTY,nIVINO DIMFNSIONS AND Nonm DInFC710N. EXPANSION OF SFWAOF DISPOSAL RVSTFMN. <br /> 1. DIMFNRIONED OUTLINER AND LOCATION Or ALL FXIRTINn AND rnoroaFb R. LOCATION Or wFil.R WITIIIN RADIUS Or ONE IIIINnnrD FIFTY FT. <br /> SfnUCfUnER,INCLUDING COVEnEb AREAS ELICIT AB rATIOR,DRIVEWAYR,AND WALKR. ON ,IF PROrERIY On ADJOINING 1'110PETITY. <br /> L� <br /> r <br /> x, <br /> r� <br /> ti: 7 <br /> y i 1. `Z. <br /> nlrt�ti p 1/FI . <br /> VFrAnIMENT UNE ONLY <br /> App11-11,e1 Aenenle,l fly L. <br /> - b•re Mee_ <br /> O.mrl In•nwe llnn R � �^ <br /> Y O•te _P4m.p In•peellen <br /> ce..,n.e„rr <br /> ACCOVNIING.ONLY: AID/ --- FAC♦ <br /> PE COVER TEF INTO_ AMOUNT REMIT IFIT rClIF!CMARll—1_RECEIVED Ry DATE PERMITIATTWICE nEGUENT NUMRErt INVOICE <br /> Pub.Hnalth Serv.-Enviro 173(3/96) <br />