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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OMSION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 06202 . <br /> (202)46&3420 `, <br /> NON-REFUNDAIR►ERM11 U0111 I TEAR FROM DATE 111911 3 <br /> IGgMa he TryfrW <br /> NPUCATION M HERE M MADE TO THE SAN JOAQUN COUNTY FOR A RAArT TO CON{TI{JCT AND/OR#MALL TM WOR(DEKNIGID.TT/{APPLICATION 16 MADE N COM'UAKI WITH SAN <br /> 1 JOAOUIN COUNTY DMLOPLIE R�TIT LL`CHAPTE!1$-A 19.3 AM)THE ETANDANO{OF EAN JOAODN COUNTY PU%UC�HI�AL/T�N SVM"{,Br^'%OW'MAL HMTN OMOOON' /�/� <br /> JOS ADOIESLOR AFM/ -/may//:'qG nl ll'Agz!L _ CITY- mpkl- �f1 'ARC.. 2.37-2W-Q} <br /> OVR4R•{NAACO 1 1I!{ 40.'Ak���A IASLA ADO.$ZJ1 ���s �\16 C'1 "vNE, ry 335 <br /> cow RACIOR V 411 r..'(lG 1ll'1[C IAI(i 1---1= - --AmF[M--0.TV`-x S�^!01U,I�Si�-CICU 2C� b FNOME A"J�LL"'�(� <br /> .N/.sN. ''Ir l"'1 h NICsE I�►.)V RC1►.R`V►�1�L. ADDIIE.: S1 Vu1(L.N1.,��'UC: ILkv <br /> r(n:?YLwAVMft ❑NEW Wal ❑AmAcEMENT WEu JH MGMTGIMFG weu.�// 2 ❑OTNNI <br /> ❑WwTMAAn M ❑WELL MTEM FVAJA /❑CrogComacT""AR vAFpl EXTRACTION Nal E .' <br /> O N...❑R-.W HJ, Dt"N HN.1►QT_JT. /` FM WATER uVR r ^Q f 0 <br /> (1 YPE OF PUL4m ❑OUTO►-RRVKE Wtu ❑ocorwacAL WELL F ® WORL w1Wtq `J J C.C!�PRiJ 47` -'•R <br /> ❑DEErnIcTDN X?C r �l <br /> WELL cokitavc1lom IMPw A <br /> ❑P VITAL D OFDI SOTTOM U.DOf WELL EIICAVATIC I DUL Of CONDUCTOR CASINO �•�' ' O <br /> OM <br /> ❑DOMESTICANFSVATE 13II <br /> GRVR rAoumi TYRE Of CAENEL.F'V <br /> OAITEC N GIA.Of MRL CASOM NA O <br /> Cl HAUCMUNlCrAL ❑ORVW DEPTH Of GROUT RAL ' r a 4'RfbA )1 {FccncAmm U-,4• R <br /> ❑S{SOAT)ONAO ❑OT"m GROUT WEAL NCTAU D 9Y L y 1(I!7�• OADUT SRAJID NAME je-r1AAAP R <br /> ❑YOMTdWrO` ,r GROUT RAL KMM&..❑Y- ®N. CONCRETE PEDESTAL SY DARAM❑Y- ON. R <br /> APPMOL DVTH 1 X CO/ �X�X/r tocKm cMRER ooxwTOVE PIE -A s <br /> fRO►OW®GON$rRUC"OMA I LUNG METHODS MUD ROTARY M ROTARY AWER cAN{ --OTHErI_k' <br /> I LEVY CERTIFY THAT I HAVE PINNED TMS APPUCATION AND THAT THE MOM(WILL R DONE N ACCORDANCE WiTN WAN JOAOUN COUNTY OMMANCES.RATE LAWS,AND NAER AND <br /> REOIMTDNS Of THE SNI JOAOUN COUNTY.HOME OWNER ON MENRD AGENT'S MGNATVIE CERTIRS THE POUCINN,7 CERTIFY THAT N THE PEWW"ANCE OF TIRE WORK"VO" <br /> THS PUMIrT M MEMO,1 SHAM NOT UAKOY PERSON{SU{JECT TO WOMMWS CW4MMATION LAWS OF CAUFOMEA.-COMTNADIORY MOM M KA•CONTINCTNO SIGNATURE CERTUNS.. <br /> THE FOUDY A10: -1 CERTIFY THAT N THE PUEONAANCE Of THE WOrK FOR"NCH TM KANET M NEUED.1 MULL EMPLOY HJBONE 9UJECT TO WOHIOAAWS COMMSATDN LAW{OF <br /> CNiORPSA.- TIE M ANT WAT CA4 N NOUB N ADVANCE N ALL REoLWtm NE►{OTIONW AT Wdl 4OW442L COMHlTE DRAWNG AT LOW"AREA PROVIOW- , <br /> �? 1f ««1 <br /> ■ T.. S �r c. ` D-.� <br /> FLOT HAM 0'—N S." <br /> 1.MAAES Of STREETS OR ROADS 1EAIEST TO OR SOUNDIM THE PROPERTY. t.LOCATION OF HOUR SEWAGE DISPOSAL{YREM OR r11010RD •, <br /> E.OVTIM W THE P110PEJTTY.OIVNO ONAENMOMS AND NORTH D111EGTION. EJVANMD OF RWAOE DISPOSAL IMM. <br /> NA <br /> .0 [NMOn.ED OVTIRrAND IOGTTDN OF ALL UI11TN0!1110 PROPOSED {.IpCATDIMM.WRL NTTI1111 RAW*OF ONE HUD11E0 FIFTY R.+ <br /> STRUCTURES.NCLUD*4 COVERED AIEJIW SUCH AS PATDS.DINEWAYS,AND WALKS. ON THE HIDPERTY 011 AOJORIRq PROPERTY. <br /> .. .... i E .......:...... <br /> .........:.... . <br /> .... i.. <br /> ..........:...>... :' <br /> : . -• <br /> 1 <br /> 1•.H <br /> .' .. <br /> R <br /> T <br /> ....:......i .. <br /> i <br /> .. .:.....! .... <br /> ...t....!.... ........:.....:...... .. i:. <br /> �............<..........'.. <br /> .... <br /> ...i.. ....q... ....... ii <br /> :q.... i <br /> .........:... <br /> ....l..... r....�......a. <br /> ! .. -ir <br /> ._ .._ '! <br /> .. . { 77 <br /> ` <br /> .. <br /> i <br /> DAARTMMR DEE DULY <br /> Vol <br /> o-A MP..o-Wr Ow. Pvry Y-P..O.P N 0-_: <br /> D.R. <br /> 0. Pli cleHD <br /> n r u,ry <br /> Ac COUMTNO ONLY, ADF IACI <br /> h coon FR INFO AIAOUNT REMTIED CHECKMASH RECEVED SY DATE P9{ATISMIVICE MOMT NUMBER NVWc{ <br /> lqo Z DU Z 3 <br />