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APPLICATION FOR VVELLIPUMP PERMIT <br /> SAN JOACWkCOUNTY PUBLIC HEALTH SERVICES • <br /> EN MENTAL HEALTH DIVISION <br /> P.O.BOX 988r 904 FAVFWEBER AVENUE,STOCKTON,CA 95201588 <br /> (209)4983420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICImplm M TIIpn t.1 1._ <br /> A,THE MW MXFMD. <br /> NOT <br /> MWN COUNTY CATION 16 rtpfVEL FMEEM TITUF,,N UY MAXNE TO THE BAN,OAMIN COMMIER 8 1116:AND THE BTNmAM I Of SM".MIN CA To CONSTRUCT ANDMA IO�U,',y,,L,M�OOU��I/'yEN�MyF,,6ENVICFBNENVIMNMEWA'NEKCATIOH 19 M IdVIBN1N.ANCF WTTN-AN <br /> A9 ADDIMO.N AME JJtS/�W✓✓ Di CRY -�'K•F�/VE! �PAREL ARwAMF <br /> ADMEEB PO fj2 13 PIbM I 1 <br /> OM'NEA'B NAME �-n�'I� OII 6--&e <br /> __ �]T1y L-y��rw, v'1`vE'777F— <br /> COMINCTDN�a�Ii F��� ADdEAWWJ 6?2f oW S[!/1_Y(ICE N.� FINIM. <br /> Bw COMIdCTON 2.;22.;2-31(/{ ,KIncda LIOE (0/726/ MOM E 851 i <br /> V A <br /> TYPE Of WEU/wMP. ❑NEW WELL ❑OfNACFMFM Wfi1 ❑MONROPMVi vrELL1— ❑OTHER <br /> ❑m(TAUATXIN ❑WELL fVATEM PEPAIN ❑Cro86CONMCT IIFPAIN ❑VAMNF%iMCT10N NEVE <br /> ❑NwvO MYr N.P. <br /> DEPTH MMP BET----FT. FIAMWATEAUf O <br /> .UYYREOFMWJ , '❑yOw.,.mNCE mu ❑OF01M'®CK W4LLI ❑ pll MNNO d <br /> Eq--TAM M)N: ��E tiYT(/ ���/ <br /> / ` CONATAVCRON ArtCHICATIONA A <br /> INTENDED WE TYPE OP WELL �] D <br /> ❑IHWeTPoK ❑ PE <br /> ON MTTOM dWE <br /> DIA. LL EXCAVATION �t1r �I DIA.OF CONWCTONCAMNI .6'� <br /> ❑OOMEeTIGIMVATF ❑OMYEL PACKIAIEE TY140FCAMHO/REFI Li� dA.OF WH1 CABd0 Tv O <br /> ❑p,j.M'VNKIPK ❑OwvEN OEFFNOF ORM BFK /`� AV£CNICATX)N A <br /> ❑...O TpHIAO ❑OTHER OR VT AFK IHATMIEO AY OroM AMNO NAME E <br /> ❑MouErowNo Arovr AEK wMPED:❑Yu OH. COWRIETEFEOESTKAYOMLLFR:OYu ON. s <br /> Arww%.BFRru <br /> LOOMING CHEATER R%(.TOME RPE s <br /> AIA MTAM AWER CA _OTHER <br /> RIONAm CONBTIYCRONIMWND METHOD:MW RTAM - <br /> 1 NErtAY CEMNY THAT MAVF MEPARO TNI.AERN.ATMN ANO THAT THE M.6 MALL BE COHf N MCOMANCE WTTN BAN AAWIN COIIMY OfldNANCEA,STATE(AWB.AM INIFB AND <br /> gEOV1ATN]OR OF THE BAN MAWm COUNTY.HOME <br /> ONMER OR MENBFD AOEM'A MONATVRE CER11F1E0 THE RLLOWNO:'I CERTIFY THAT m THE PENMRMAHCE OF THE HOER RA NMICH <br /> FMMA ANARM IF THE SAN.-MIN OVNTPHOME AIER TTOWONIUAN'SCOMFENAAMNUWAOFCNIMMIA'CONTMCTOWBMPoR ORNBLONTMCTXNiAMMTUIE CERTRIFA <br /> IN µCK FOR I'JTA <br /> THE FOLLOWING: •1 CFATIFYTHAT IN THE F WORMANC/.E�OF THE�JMW RR"MH TMA PF MIB <br /> CISSUED.I BXALL W0.0Y FfRWMB BU6IFCT TO WOMTEFJI'A COMfFMAAQINIM UNT OF <br /> MIFORM.I.' Nf �Y nMVATCF^ C/KILLRTMIIER �� /��/ <br /> ec t{f rAT OHROI Ap.NSB,COMRFfFORAWIRATLOWER II I-9� <br /> //gByqrr z V /F/I'/r�) <br /> /S �R y/YJ Mlle E IDT RAN v I.Bull Aul.�•Ian <br /> `` l L)CAtION OFMwEBFWAOF dBFOBK"'T"'N RNIPoBFD <br /> 1,NAME OP eTRfET80R roADB NEAWAT TO Ofl NdR THFPNORMY. 111M.1 OF OEWAGE DNMOK AVBTEMA, <br /> E.OUNNE Of THE R1dERTY.OINNG dMEHBgNB AND NINTH DIRECTION. B LOCATION OF WELLS WRNIN RANUB OF ONE HUNDRED FIRM FT. <br /> ].WMENBmMM D MTUWO ALOCATION OF ALL E%IETINO AMC F M)MSEO ON THE PMFEN Y OR ADJOINING RORT <br /> F4Y. <br /> STRCTUREA.INCLUDING COVERED APFAE BUCN AS PATIOS.DMVEWAY S.AND WAL(A, <br /> e W.rE ue1NExRw. <br /> N 7Dv <br /> µ <br /> 1 ^1 <br /> uv:F a MA. , RAMP <br /> e E, urv.9A 4M1/rw.IMr/.Mnmrpwna LOUAn' wCEFwmv <br /> ., Wnr®Ow14uME uNDNrvMIKx wbuv.v.A 61M[I[w <br /> I <br /> uw.e• TLO ImM G,...rB pxwrr4xrtnwaur4wmvrtu EacAwrlum oE6reuliw <br /> WT- LOFF- <br /> �OW <br /> OP- <br /> I w uwnF <br /> I u R <br /> N,r.C�w°m <br /> r-- <br /> e NxG <br /> e .R evxa <br /> w.r.wvE4wrniro-wLw.u.wx.,.rl. ,r..w <br /> E <br /> nu <br /> P'46C Maa'F°w vRO—t I <br /> \bEGAd 'w <br /> _ DERAATMeFr we DNLr <br /> IOM <br /> NPlwrkn Aeegr.a Sr <br /> G.rM A.pmllen Br <br /> ON. MFF Ir.P.ea.n <br /> OM. <br /> DSPNnI.x In.pslleN By <br /> comm <br /> ACCOUNRNG ONLY: Mor FACI <br /> PF CODFI MINI AMMINT REMITTER CNECOMASH AFC IMED AY DATE PERNRTM61VICf REMIEST N.MR INOAM <br />