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. APPLICATION FOR WELLIPUMP PERMIT • <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JOAOUIN ST.,STOCKTON,CA 95201389 <br /> (2091468-3420 <br /> NOW-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICOMPAIR AI TTyO/eM) <br /> ARVCATHIN IS HEM BY MADE TO THE SAN JOAONN COUNTY MR A WAIT TO CONST WCT ANORIA FMTALL THE NtlR{DESCRIBED.THIS AWEECATpH le MADE M COMITANCE WIIN SN, <br /> JOAOD N COUNTY OEVELOMEM THD.CHAPTER B 1116.3 AND THE STANDARDS OF BAN JOAONN CO)yNIY FORM HEALTH MN.ES.ENVIRONMENTAL HEALTHHEALTHW.N. <br /> JOBADORENHOR MITRE pIIIIA 1[ V4491ut.A,ORIK %rlegrnA 5E IF"-w,7104yOM PASCAL SM .1 <br /> OVMER'B NAME Clf 1, of 570OV1 ACORF88 SHORES <br /> eoNTNcron)7 a1taFL:d (A tR F=n FlPORNL•k7a1 ADD--i!oj w, ,Ik Ln!F LICE RRONE/4F6.026 <br /> NB CONTRACTOR ADORERS VC/ WIp1Et <br /> TYPEOFWwFD.P: ❑NEWYRLL ❑MRACEMEM WELL ❑MOMLOWHO WELL/ 13 OTHER <br /> ❑INSTALUTpH ❑WELL SYSTEM PEPAM ❑c...0...OCT REPAIR ❑VNOR E%TMCnON Wn1I J <br /> ❑Nw OPgW, H.P. DEPTH IMF NET FT. FROST WATER LEVEL �I <br /> O \_ <br /> (TYPE OF MAN, <br /> ❑ FBEIINC � <br /> DVT-0E WMI ❑OEOPIY6ICAL WELLI R, <br /> yBBM1 BOPoNO Il.a PK GP a <br /> ❑DEST.T.I. <br /> INTENDED VF TYR OF WLLL CO PTPVCTIOM SPECINCAMXS A <br /> ❑IWurwAt ❑OPEN BOTTOM gA.OF WELL E%CAVATIOH SAF "A,OF CO.. O <br /> ❑OOMEBTICR ATE ❑OMVEL PACIIMEE TYR OF CANNOBTEELRVC A.OF WELL CAM. �- O <br /> ❑MIRW .x IFN 0 <br /> OW4Fx OEFTH OF FOUT REAL }2 TOTr SPE<DICAnOx n <br /> ❑INVOAnoxrAO 13 OTHER OWVT REAL.ENHALLFD BY RECHT BMHO NAME_PS PIY IIed CeFRELLT E <br /> O MoxrtORNG DRODT REN NHESM:❑Y- ❑N. CONCRETE PECESTA Sy Mum,❑Y- ®N. a <br /> A...eFFTx 32' LOLPMO CHORES W XROYE nR <br /> Ruh a <br /> PROCEED DENIEV <br /> ITCMNIdETHO <br /> RWNO MD:MW ROTARY NRROtANY AUNER CABLE HF <br /> OTRDIASCH I Ruh <br /> 1 HEAMY CRATIFY"AT I HAVE PIEPAIRO THIN AMJCATpN AND THAT THEW WILL RE DJNE IN ACCORDANCE WITN SAN MAONN COUNTY ORDINANCES.STATE UWR,AND R x,oll ZED <br /> PEWI.ATpHB OF THE SAN MAWIN COUNTY,ROME OWNER OR MENEM AGENT R SIGNATURE COARNHEPo <br /> S THE LLOVANO:'I CERTIFY THAT W TNF PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS EERAR M ISWED,1 SHALL NOT FM0.0Y PERSONS SUBJERTO WOREMAN'9 COMPENSATION UW9 OFCAROWSA.'CONTRACTORS HIM"On VVB .NTMRMO SIGNATURE CENTERS <br /> THE FOLL0 W: '1 CERTIFY THAT IH THE FEROMAANCE OF THE YVG K FOR WMCH THIS PERMIT IS MWEO,I SHALL EM Y IKONS SUBJECT TO AHRIMAN'S COMPENSATOR LAWS OF <br /> CN ORHIA' THE AMCCiA�NT HENT CALL'N NOUN IM ADVANCE iOP ALL P[OVRQ)IXERCTMNR AT ISMI/.tl.MEi,COMAFTE OR/,WINO AT tON411 AREA FIbVIOpEO. <br /> BIFW%� FYLC THI. s,A;.e s�af� V.t�t��:r Dn. z-I[ •Qy <br /> ROTMAROFw I.M`N <br /> 1.NAMES OF STREETS OR MADS NEAREST M 09 SOVNDINO THE PROPERTY. A. MATCH OF WINE..OE.MVeN SYSTEM ON RROPoEEO <br /> R.OMUNE OF THE PROPERTY.OINNO DIMENSIONS AND NORTH MMCTION. I.P W SIGN OF SEWAGE OMMBA E.H.SYST <br /> 3.DIMENSIONED O VTUNES AND LOCATION OF AL EXISTING AND P ROMSED e.LOCATW N OF WEDS WRNIN MgVB OF ONE HUNDRED MM FT, <br /> STRUCTURES,INCLUpNO COVERED AREAS SUCH AS PATW S,DRVEWAYS,AND WALKS. ON THE PROPERTY On AOMOCNNO RROMUY. <br /> OBAIETMTAT D.L BIRY <br /> APPS-Om m"N.n BY <br /> OrwR N+P•.QeR W DH. FunP I+R.INR er Dn. <br /> n..PNnI.R Irvemllm er DH. <br /> c.n,m <br /> -COURTIN.OM3: AID' EACF <br /> PF COOED FEEIHFD AMOUNT REMITTED NES... PECBVFO RY .-TE FWAITIFDWICL REQUEST WAITER INVOICE <br /> CO � <br />