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<br />APPLICATION FOR WELVPUMP PERMIT
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<br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br />ENVIRONMENTAL HEALTH DIVISION
<br />304 EAST WEBER AVENUE, STOCKTON, CA 95202
<br />(209) 488-3420
<br />ROTI AEFUIEOARIE PERMIT EXPIRES 1 YEAR FROM OATS 133UE0
<br />(Ce1RPl1h M TrIpREE111
<br />APPLICATION ION N HERE At MADE TO IT CAN JOATAR 1 Cp1RTTY FOR A PEPMR 70 MNBt",IT ANDID, INSTALL THE mW. DE6CRIREO. TIRE APPLICATION M MADE IN CDMPUANCE WRIT SAI!
<br />JOAOUN COUNTY bEVEIOPMENT TITLE, CHAPTER S-1 116 3 AND
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<br />WE 64AEN��O,�APM OF 8AN JOAOUIN CO�jN�TyY PUS`UrC HEALTH SERVICES, FWAMNMEMAL HEALTH 011 i1
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<br />PROMSED CONNAI/CTNIRM"LLPM METHOD: YJUO 110TARY AIR ROTARY AUGER CABLE OTHER
<br />VIA. OF WELL CA8 O
<br />W-ECEK`ATION R
<br />GROUT SRAND NAME E
<br />CONCRETE PEDESTAL SY bftLL"! E] Y..
<br />s
<br />IOt&A CERTIFY iNAT 1141VE PREPARED TMS ATRICATK)M NA THAT THE WOTK WILL OE DONE N ACCORDANCE wRll UN "AMN C-'WtY FI
<br />1~-ANCEE. STATE LAWS• AND MILES A-
<br />REOLLITOM OF THE SAN JOA0IRN COW". NOME OIWI1111 LICENSED AO 111-1 11NATIAIE CENTE'[C TN! EO LLOWR: •1 CERTIFY SHAT N THE PERfOR11ANC! OF THE NARK FOR WINCH
<br />TNM PERMR IS t1/l1ED. 194 ALL MDT TMPLOY PEROONS RLWECT TO WIXMWAW. ca MrENE A MN LAW/ OF CALIP FMA.• CONTRACTOR'S HS1/1O OR SUSLOMYtACTNO ■10NATVAF CERTS-NS
<br />TIE WLLOWINO: • 1 CEIRIFY THAT 111 THE PFIFOPMANC! OF THE
<br />WN'CFDA1! "
<br />OIC
<br />WHH THIN FE/11fT' IS 111LIFD, 1 /NAIL EMPLOY FERSONE SUSJECr FO tARN11p,TAWS COMrOrIARON L1W4 (W
<br />CAII9FN1A.• THF M T /�,yH}O yW W ADVANC! FDl1 A11 RFOUR® M1lEC T10pN1 AT ISMI Ap-fLM. Co"` ETE DRAWRA AT LOWER NEA PHOVto"-
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<br />S. OUTtine Of TNN fROIETTIY, OP-" Or1E49H)N/ ANO NORTH VI ECTION. E%PAH11pN OF SEWAGE Dlm{vSAL SYSTEMI
<br />J. EM1.1lNS:ONFD OVTLNES AND LOCATION OF ALL FMSII FM AF10 PHOPUtED F, LOCATION OF VYEWAtLw WTTT11II RAON1 of MS /RINTAEP FYTY R.
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<br />Accolmnnp oNtY: AIDE FACA
<br />T! COCE■ TEE INFO LM RET.OTTEt)
<br />AIN RECDVED ST FEM-TISMACE REOVFET NLRAItM INVOICE
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<br />Pub HeSMA Serv.- Ermro. 173(1/97)
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