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AFFLIGATIONFORWELL/PUMP PERMIT <br /> — SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIC=S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 'I'mosis' 304 EAST WEBER AVENUE,STOCKTON,CA 952Crt <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (c fSplels I <br /> APPLICATION IB ITEM MY MADE TO T11E RAN JOAQUIN COUNTY ron A PERMIT TO CONNYRUCTAR <br /> NOp/1 INRTAu.THE WOIK bERCRIREb.VNIS M7gMATMN IR MADE IN COUNJANCE WIIN RAN <br /> JOAQUIN COUNTY OtWILO"AFTIT THLF.CNAPTER 9-1115-3 AND TIIE STANDARDS OF RAN JOAOUIN COIInty M/RLIC IIEALTN SERVICER,ENNIgNMEMAL NFALT"DM@ION. <br /> Joe ATMMSSroR APNI,�V �5�/1�• L ,p�� S.�.T-al(- city_Atll-k�A_CQt <br /> OWNEn'S NAME QS PARCEL MZE/APNI np {L <br /> ATS ADbMSS G�+J S•LtKW�vt S-� MgNE1�."F CJ�1-S�ZU <br /> CONTRACTOR_ "T`� .Su'Yti�� r{y�y\J`�.ly AbD11ESR�tbJ' (J�.pk:La „�Jt, o I <br /> SUBCONTRACTOR ^4t <br /> hL1l , 1 _1 Nr.Sf��t.1�o M40NEIlo95�-ry-Zzz.l <br /> AODMRSJ L�7 F"iT r41� IC•�. F:4c1.-1 t)CI�TL�I� 4�^j_u <br /> ^^• MIONE 091U <br /> TYPE OF WELUPUMP• NEW WELL ❑REPLACEMENT WELL VMON IORING WELL I 3 ❑OTINR <br /> ❑MRTALLATION ❑WELL SYSTEM nF.rAln ❑CRDe9-CONNECT REPAIR ❑VAPOR EXTIIACTMN WELL <br /> It <br /> ❑New❑R•RNr H.P. <br /> HYPE OF PUMn TIEPIN 1•UMP RET__FT. FRIT WATER LEVEL O <br /> ❑OUt-Or-BERvIcE WELL ❑OEOMIYRICAt.WFII I ❑ RON.ROn,NO <br /> S <br /> DE9TnVCT10N: <br /> N/ENbEO VME TYPE O WE CONMIRUCTION MPECIRC—IONS <br /> ❑INDUSTRIAL ❑OrEN rTOM RO (� � <br /> DIA.OF WELL EXCAVATION VIA.— GIA.OF CONDUCTOR CARING f`I�•' O <br /> ❑DOMERTI;A9RVATE ❑GRAVEL PACK/BRE TYPE OF CARINO/RTEEtTVC P\G DIA.OF WELL CASINO Zr <br /> ❑runfac"UMCM/N. ❑DRIVEN D <br /> bEPTII OF GROW REAL_ '.�• er'ECNICATMN Slbl 4 <br /> ❑IIRIIOATMNIAO ❑OTIIE.n GROUT REAL INRTALLED�RyY (11 � ,AVA E. Snout RMNb NAME <br /> GROUT <br /> MOMtOnINO 'jC OVT SFM/MFED:81 Yw ❑Ne CONCRETE t•EDERTAL RY DNLLF.n:Ely- Mw. <br /> APPROX.OFTKH �' 3S LOCKING CNERTEn BOX/STOVE MPf_.Ay _ I <br /> MIOPO9ED CONST1111CryONIDRIlUNO METHOD: MVO RDTAM' AIR RD7ARY_-V-' S <br /> CABLE-AUGER OT"En <br /> I HERESY <br /> CEntIrY 71/AT I NAVE PREPARED TMR AMM1JCAtMN AND TIIAT THE WOW MOL R <br /> two <br /> BE DONE IN ACCORDANCE VAT"SAN JOAQUIN COUNTY ORDINANCE@•STATE LAWS.AND ULER AND <br /> to" 1 <br /> Ut AT0N9 OF tow RAN JOAQUIN COUNTY.NOME OWNEn On LICENSED AOENT'B RIONATUM /n CEIFIEB TIIE FOLLOWINO:'1 CERTIFY THAT W THE PE ronMANCE OF TowWOW TOR WTIIC/1 <br /> TRIM FfnMIT IOF <br /> R ISSUED,1 SIIAIL NOT EMPLOY T'ERBON@ RUBJECT TO WORKMAN'S COMMMIARON UWR OF CAUFORIIIA:COMRACTOR'R'MIND OR RUR CONTRACTING SIGNATURE CERT VIER <br /> CALRO <br /> TIIE FOILOWINO: •1 CERTIFY THAT IN TIN!PEMORMANP.E OF 711E WOW FOR W111C11 71115 1[MtIT M IRIVfD,1 RIIALL EMPLOY FEn9ONR SUBJECT TO WORKMAN'S COMPEN•ATION LAWS MSA.• TIIE APMICANT MUST CALL t/HOURS IN ADVANCI FOR ALL REGUMED INSPECTMNM AT 1"91/9/9..$421.COMPLETE ORAWING AT LOWER AREA PROVIDED.p�2 <br /> SIIrW X / AAAA 9. AS a.•I TIO•�.A[1,11Lc Yt F E l 0.1`/�LIKS.CJ� Die•__",S,� 1 [ <br /> oma---- <br /> ►LOT PLAN Ph—1e Rerl•1 SeeM 're <br /> t.HAMER OF RTM"ll ON ROADS"TAMEST TO On ROUNWNO TIIE TTKTIERrY. <br /> OIN1.LDrA7M)N OF 110UBE @SWAGE bteRDSµSYSTEM OR T•1101.ORED <br /> 2. LINE OF 111E"torERTY,OIVINO DIMENSIONS AMD NOW"nwrT w r.n.e.......�. ..-�- -_ <br /> e.DIME.NRMNED Ot <br /> STRUCTURES,INC rY h. <br /> 133a1s NTooNn � � <br /> �N� F� <br /> Qo <br /> Z J 00 rc W 1a• <br /> (� u SOU Q oaQ Q N <br /> 2 a0,zvWcxUs <br /> a°- <br /> t� <br /> �FZ � <br /> aW H <br /> a 0 Z rh <br /> n a z <br /> M � f <br /> � 0 <br /> � N 1 <br /> �5 <br /> a gJ <br /> •gym <br /> `JNIGllnB 3Jv801S2 vi <br /> O M <br /> A311Y <br /> C L T H <br /> LJ 2 � <br /> J � <br /> V£019606 B3ewnN . <br /> �NIMYaO <br /> DEPARTMENT USE ONLY <br /> Grein Im•rolien RY Doe Prey Ine••eeen SY Det. <br /> D•rr.rell•n M.r«:rbn RT <br /> D•1• <br /> Cemmr•Ne� <br /> ACCOUNTING ONLY: AMI FACT <br /> FE CODES FEE INFO AMOUNT RFMITIEO CHECK ICAIN I RECEIVED IY f OA1E I.T/MERVICE REGUEMT NUNR61 INVOICE <br /> 5� 4 cd IZZIL111°•9 OlLi 1,z <br /> Pub.Health Serv.-Enviro.173(1/97) <br />