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-cw s APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 38%304 EAST WE81=R AVENUF,STOCKTON,CA 95201388 <br /> (209)46113420 <br /> N REFUNDABLE RMIT EXPIRES I YEAR FROM UXTE ISSUEO <br /> ICempMte M TrIon"Iml <br /> om <br /> R NEPE ry WADE To THE BAH JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDROR INSTAL).THE WORK DERCOSED THIS APPLICATION IS MADE IN COMPIAHCE WRIT SAH <br /> bEVELOPMpT TREE,CHAPTER 11115 1 AND THE IETA/NQARDS OF SAN JOAOIMN COUNTY PUWX HEALTH GERVICER ENVMIONMENTAL HEALTH DIVINON <br /> ES <br /> JON AbbRSAA APNS rI r. f CTf FARCEL SIZErAPNf <br /> I r <br /> DWNERy NAME <br /> C MRACTOR /. ADDRESSe3iei c' Qo nwmE � <br /> w <br /> SUBCONTRACT r� A0071 > EIC, <br /> c s f�i 7�i F,.DIIE -72ADDRESS ,E <br /> 7YPE w YYLIUPLNHPi E]HEW WELL ©REPLACEMENT WELL ❑MONRoRINO WELL• ❑OTHER <br /> ❑INSTALLATION ❑WILL SYSTEM REPAIR ❑CROsi-CONHECT REPAIR ❑VAPOR E%TIIACTgN WELL I J <br /> ❑H—❑A"" H P DEPTH PUMP MET_P'T FMfT WATER LEVEL O <br /> TYPE OF AIM% <br /> 0 y <br /> awT or SERVIcE WELL ❑GEOR1YOlCAL WEIL• / ❑ SOIL Go"m ! <br /> 7" ,,,f � <br /> DED tiff-TE-MRu tiff—TE—MRCONSTRUCTION SPECWCA IONS A <br /> 133 RoverwAL ❑OPEN BOTTOM DIA OF WELL EKCAVAt1ON DIA OF CONDUCTORCASINO p <br /> 13bometriESVATE OauvmPALTLREIzE TYPE OF CASINO/STEELMVC DIA OF WELL CASINO p <br /> ❑ARKxmuNICWAL ❑OWAN DEPTH OF GROUT SEAL ■TECIFICATION R <br /> ❑MOATIOP MAG ❑OVHMR GROUT SEAL INSTALLED BY GROUT MWID NAME G✓Y _ s �y w r 7r E <br /> ❑MONRORNO GROUT SEAL PUMTEO ❑Y.S [IN. CONCRETE PEw rAL by bIVLLE1L❑Yr ❑NP s <br /> APFwX DEPTH LOCKING CHESTER bOkRSTOw PIE S <br /> PIDPOSM OONETRDCTOMANKUNO MIlHob MUD ROtARtY AIR ROTARY AUOER CABLE OTHEJ,_ <br /> I"E'"Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION MRO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAAUIN COUNTY OROINANCES STATE LAWS AND ARES AND <br /> REGULATIONS OF TIR SAH JOAOUM COUNTY HOME OWNER OR LICENSED AGENT a SIGNATURE CERTIFIER THE FOLLOWING I CERTIFY THAT IN THE$1WORMANCE OF THE WORK FOR WHICH <br /> THISPtRYOT KISSUEO tSHALL NOT EMPLOY PERSONS SUBJECT TO WOftWAN a COMPENSATION LAWS OF CAUFOIEIA. CONTPACTOR S WRONG OR SUBCOMRACTOM MMATUM CE"Wne <br /> THE FOLLOWING. 1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHOCH THIS PERMIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF <br /> GtL1pN 711[AyLRCANr MUST CML EI FbURs MI ADVANOE Fb11 ALL REOUREb IMiP/LCt1OMs AT 12081 4094422 COMRSETE OMWINO AT LOWER AREA PEgV1DEb <br /> S4rMk �� TRI. �•.f-,r�-/ I'-`!�."/ f ..,. O•er_.� �/ -IF <br /> PLOT PIAN Idw+a Swl.l Sed. n <br /> I <br /> NAMES Of STREETS OR ROAbs NEAREST TO OR ROUNDING THE PrmRrY M LOCATION OF HOUSE SEWAGE WwoGAI SYSTEM OR PROPOSED <br /> e OUTWNE OF TPR PoorwTY amm OIMEHSIONe AND NORTH DIRECTION EKPANOON OF SEWAGE OtePOSAL SYSTEMS, <br /> S DIMENSIONED OUTUNFS AND LOCATION or ALL ERRsrom AND PROPOSED S LOCATION OF WILLS WHt111N RAOlUG OF ONE HUMORED FIFTY FT <br /> STMOCtUfft INCLUDING COVERED AREAe SUCH At PATIOS,DIEVEWAY11 AND WALKS ON THE PROPERTY OR AOJOIMNO PROPERTY <br /> fµ <br /> 1 DEPARTMENT weaR).r <br /> AFPe••II�Awg1•S 67 4111".1� - „. .. .. ...��wN X• 1 r k—! C <br /> O1•.I B.F..IIH.by D.n Fume MHP•HO-SY D•I• <br /> D-IR.I.R lrrr•H4.eY Ow- <br /> C. 4/1. <br /> ACCOURTWO ONLYI AkO1 FINE <br /> FEE INFO AMOUNT RFASTtEb C MASH RECEIVED SY bATb ►fleMTNHtVICE REQUEST NLMeaI INVOICI <br /> Pub ftM SKV-Eor*O 173(M) <br />