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d4 19' 1J `� '5w88 CH2)1 HILL Z 003/009 <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> l N JOAOUIN COUNTY PUBLIC HEALTH SERVICES �� 3 <br /> P.O. EtOX ENVIRONMENTAL HEALTH DIVISION <br /> 386 5w EAtr MUM AVENUE. STOCKTON, CA%Ml Sae <br /> �o el � NON•REFUIIRMIE PERMIT SMIFS I YEAR FI{0■PATE MSVFD ORIGINAL <br /> {E'NRIFINw In TrYTR1EE1 ApRNCATiON 1 NFAE TO THE BAN JOAOUMN W UMY fOR A f[gMR TO CONSTRUCT ANOI INCYR,THE MW DESCRMEO.THIS APOLICATION w MADE IN COMYIIANCF WTrn SANIw�j(A,K <br /> "AQUA COo N MMO-gW MM CNAPTIA gt 115,3 AND THE��STANCRACM or Sµ JDADUIN COUNTY PWRX HEALTH SENVICEN, <br /> JOS ADOAEINNOM APPAil -G -�l 0 7 W. ENVMONMFMAL HEALTH wVISON. <br /> C CRY ^Tc�IG�-s,—, IARCEL SRFIAg1P <br /> OWNER'S NAME .�J ( 2rrn1 .DOME.. �o2S W l�e Lz{-1 <br /> pR G SHOW 0 <br /> AD Ra& -)uGy�a yNc,TA3T0 I,Dr pICN .�2D-OZf2 <br /> Nve comwT? OR ,twt DIs�ru aYl LVlP_.ADDRti Z� Vj6t V" I,O,5i 2 G <br /> TYPE OP VFELLAUMr ❑ NM•WELL ❑ RERAC(MENT MLL ❑ AIpNROMND WELL I S <br /> ❑OTHER <br /> ❑ INSTALLATION ❑ WTii SYSTEM WMA ❑ CRUNSCo.mER PERNR ❑VMOR EILT manor vmL N <br /> ❑Nw❑II.p.1• N.P. <br /> IF VIE Of PUW9 OEPTIN✓RT__Ff- FSVTWATERLEVEL O <br /> ❑ OVi-0FIIEIIVOE WELL ❑ OEOINWpCN WELLN ❑ NOR SOTNO <br /> �DESTRINCFlDN: a bard QlY1 KP <br /> IwTIWom vS{ rn or wEu. cwrµTRucmw aPEc.,DATIo_ <br /> I❑ MNDURItµ ❑OPEN BOTTOM OIA.OF WELL FXCI1VATbN pA.OF CONDUCTOR CA®MB A <br /> U DOEAEMTICTgvATE ❑CmAm PACINNQF D <br /> ❑ <br /> TYPE Of CArINDIrTEOUN CIA-CIA-Of WELL CASINO O pNNLICANUMCNAI ❑DISVEN DEPTH Or ow SEAL e4ECIFCATION <br /> ❑ IRRroATIDNMO ❑DTNER GROUT SEµ,MSY L w A <br /> O MormoRMNe oroR rRENp NAME E <br /> OPIpUT SEAL Ntowv D ❑Yw ❑Iw CONCfWIl PEbtSTALeYwEUER❑Y. ON. y <br /> RONSON-YFIrM LOWN O CHESTII NOIIROVE A <br /> 5 <br /> PROIOtm CONNTIIUCTIOwNpRRUwO MRItlD: MUD ROTARI' AM POTAw AUGER CASLL OTMERL <br /> I NEAESY CERTIFY'THAT R NAVE UM,CO,,,,,.PRN TIME APRUCATMM µ0 TMAi TMF WDRR V/ILL lE DONE MN ACCORDANCE WITH tµ AAWMI W OIr1 Y OIIDII ANCES.RATE RIND RUIfg AND <br /> REWLA710NS OL THE CAN JOwOUMN COV HOME OWNEp OR UMIR D AGENT'S MONATNIF CERTMMEN TNF r0{ wwo:-1 CERYNY THAT IN THE PEIIOMNANGE OF THE"m TER YEHICH <br /> TWO PF1OAR w ISrM,I SHALL JAI FMPLOYRPNOHS@UWECT TO WORIWYTN COEEAIWORTION UM Of CAILAWP A' CONTRACTOR'SNMVIMORNOCONTRACRNOIRWOITLMCEITINEC <br /> THE EOLLOWwq: 'I CERTIFY THAT IN THE RN"FAUWCF OF THE WOK MR WNICM THIS PF/ptT IS RNI 1 NNALL EAFROY PE/wONt NIISJEC'T TO SWOON µ'S COMP6NIITHIN LAM Or <br /> CALAOR NI ARRII MUNT C W MOW MI ADVANCE TOR RLL RE aRa,NN,,NC AT MOST .}Ea. PDENNyTE DM\VINO AT LOW411 ARU PROV amour <br /> Tim <br /> IfOT PUN ID•wr w N�.I 4PI. •t. <br /> I. NAM(N Of ST IXTS OR a HEAR9T'TO OR bOa%lQRO THE MbpERTY. 4. I.00ATION OF NOUNF Sk1YAOE VM M SYSTEM OR TOFpeED <br /> I. OUTLINE OF THE PROPERTY,9N DIMCNNONC AND NORTH PlAl!"ON. F AWO N OF r Aftt YINAONAL SYSTEMS.E. DAIIIIIII O 01114NIC ANO LOCATION OP ALL EIUSYWC AND pROR I S. WCAMN Dr•n'Ell.1 vmHIN RAd W or ONE NUNORFO rRT,R. <br /> RROC lINSC,INCLUDING COVERED AREAS SUCH AS PATIUS,OIIVEWAYS,AND WAIAS, ON THE PROSI OR ADJOWINO PROpF/1TY. <br /> DNARTMpIT WE ONLY <br /> wlblNw A..�.1 eT 0� <br /> wu L <br /> M IIwp�Il.n er Ou.oz <br /> f1.nP wp.pypn eT oy. <br /> .n.u.Il.n ewPA.Ia.•er T 0.N. <br /> ACCOUNTING ONLY: AID, FIICP <br /> PE COOP FEE L•RO ANAOUNT PPAITTm Cmac RTRYM NY UNIT Q PI/EIRTwDMCE AEOYNT wwASP IMVVICE <br /> 0 /z% 0 <br />