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1 _ <br /> _ APPLICATION FOR WEWPUMP PERMIT <br /> • SR # " v(� SAN OAOUIN COUNTY PUBLIC HEALTH SERVICES //r✓ Y' <br /> —- ENVIRONMENTAL HEALTH DIVISION <br /> AID # P 0 BOX 388,446 N. SAN JOAQUIN ST. STOCKTON, CA 96201388 <br /> FAC# 12091 4683420 <br /> INV# OMYIE MDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> INV#— ICBSPIBM I.TlgliwMl <br /> AIR- R PERMIT TO CONSTRUCT.WOIOR INSTALL THE WomL OESCNSEO.THIS APPL1CATgN Ie MADE W COMPLIANCE WRM SAN <br /> JOAWIN COUNTY DEVELOPNEEN�T TIITUL CH (Eo <br /> E STANDARDS <br /> OF SA„(JAO/A�OUl.COUNTY FUSUC HEALTH SER(NLCES.EN --EFENTAt„FAUN DRI=x. (J <br /> JD9 ADORE891OR APx/ I' 1I J � �YgsM1Eoo 1JA'L14 ' A0),� L/T . EL WZ.A.1163.340-Il <br /> OWNER'S NAME IO 1 �l A�/. AOOPE¢¢ /� �� �II(• //' .- RgxE/LA��/JO` 30-40 <br /> CONT 'TOR 61c,'R'Yr Y�'` A0011EBG zee 5 L`. IL,/IE11�EIC y IIC/G RgNElz�sy��.,a�'S <br /> WS LOMMCTOA qfY 4qu LM ADDRESS SAAtiL r IK/�//Zz(n6 CJIEpxE� 7- <br /> TYPE <br /> TYPE OF WEL..F.. ❑NEW WELL Cl REM1ACFMEM WELL ❑Nowom„O WELL, ❑ OTHER <br /> ❑IN6TA HoN ❑WELL SYSTEM FEE. ❑LWGSLON„ECT REPMR ❑VAPoR EMMCTgN WELL/ J <br /> ❑Nw.ORgr N.P. un"Puma,SET_-FT. FIRST WATER UWEL O <br /> TYPE OF RIMA <br /> `N'TDESTRUCTR N: E� Oo\uroF.cERVILE MU. ❑cwRlvucAL wfu/ ❑ wa e <br /> wnxc <br /> LV �c <br /> INTEND..USE TYPE OF w,L CONSTPVLNON GrfnPCAnonF T / <br /> ❑ WDU6TRAL Zr..OPEN Sono.�''''xxxxyyyy//yy�� � / DIA.OF WELL fALAVATION OL,OF CONDUCTOR CASING '~ O <br /> ❑DOMFemmWE.E 1. PACYJS _L/✓Li TYPE OF CA9wliTFfLPVC L4 0DIA.oFWELLCASW- II O <br /> ❑RIRLICMU.E,I ❑MVFN DEPTH OF GROUT SLK )ifCWCATION R <br /> ❑NWGAT.WAD ❑OTHER GROUT.FF;T.WFO GY OwUTeM1Ol NAM P, E <br /> MO„ROwNc r/1� Dro11T¢EOL M.KO:O Y- O w eoNcxTE xDEnAL eY pMLFER:O V. ON, s <br /> AMIYL DEPTH /O I LOCRWO CHESTER wvrtOVE RIE s <br /> ANro\w CO„STHUCTOMIMWNO MFTNOO: MUD T. AM POTFST AWE, CApE OTNEA <br /> 1 HE9E8V CFMIFY THAT 1 HAVE PRFPARO TNIG APPLICATION ANO TIUT TXE YAIK YALL eF DONE W ACCOwANCE WITH BAN JOAWI„COUNTY ORW„ANCFG.STATE-AWG.AND WlF¢ANO <br /> REDULATEONG OF THE SAN JOAOUW COUNTY. w4E OWNER OR WF„Sf0 ADERY,S GgHATURE CERTIFIES THE FOLLOMNS:Y CE,TIFY THAT W THE RUUOAMA„CE OF THE WOW AOR W„MX <br /> THIS PEMOT IG ISSUED.-SHALLOT EMPLOY PERSONS SUIJECT TO WOREMAN'S COMF[NSATom IONS OFCAUMM&k'CONTMLTORYS NIN„O OR SWLOMNUTRND"NATURE CEWSHE. <br /> THE Fo FF O: RTYY THAT W THE ERMFSAFNCE OF THE WORK MR NMICH THES PS.R 1¢ISSUED.I ENALL EMPLOY PER¢ONS SUBJECT TO SHU SMA„'S COMM.ATION LAWS OF 'T\\ <br /> CAUwN11A.' TP UC.EIT WTCILL ADVNHCE FOR ALL ENIM <br /> OED//NSMCTNUilATT YP <br /> LE901. dL2i. COMPETE DMWWG AT LOWER MFAPM <br /> wWNWDEO.�� �. <br /> GIOAr A / rIw S�Fr r rPn/G&J� o.•� <br /> PLOT PLAN NN...I.w.I Gw._ �J <br /> 1. NAMES OF STREETS O,ADAOS N ST TO OR wUNWNO THE PROPERTY. A. LOCATgN OF-USE 6EWAGF W¢R)¢K SYSTEM OR P110POSED <br /> 2. OVTUNE OF THE PNOPFMY.WNW WNEMBNINS AND ROM.oU"MF`N. EMPAHWN OF SEWAGE pSFOSAL SYSTEMS. 1 r <br /> ]. DUlUN NFD OUT WIES MO LOCATfON OF.LLL MET-NG AND PROMSED G. LOCATKDN OF—NTTHW MWUS OF ONE„U„DRED F.FTY FT. v <br /> STIMERUCTURES,INCLUMNO COVERED MEAS SUCH AS PATS,M VEWAY¢.ARD WALNB. ON THE PROPERTY OR AOJOWINO PROPERTY._.. _ T <br /> Vv,-CLP <br /> c <br /> DUMLTMFNT USE ONLY <br /> AFPYe.Nm Aaupl.S.Y <br /> ON. 2- - 7 Nr <br /> c�olx RNr�inn Ev wI. F,M,r wPKu.,av <br /> D_,�Iw w.�INN eT a -.3 5 ~i 3 E - ON. s <br /> LsMN � -7`t-eIrXB�.t. <br /> f LE <br /> AOCOvxn,O O„LY: w0/ FAC/ <br /> IF L004 PEE 1.M AMOUNT AEWTTED C... A.N AL58 Y OAT. NOWATI. NCE RMIJUAT xLMS <br /> N OZ (00/ (aCJ A 2- OfZZ0 <br /> I <br />