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x APPLICATION FOR WELLIPUMP PERMIT <br /> SIAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION � <br /> v P.O.Box aft 304 EAST►NBBr=A AVENUE, STC3CKTj4N,CA SM,_%a I <br /> (209)468.3420 <br /> 0111- EUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION le ITEpE SY MAS TO THE SAN#OAt]L?ITN ICBmp>.ttk in t'TlPlteat#I <br /> JOAOUIN COUNTY t�VELOPMEHT TITLE:CHAPTER 9-111C 5..3 AND THE STANDARDS OFTO BBAN JOAOU N COUNTY PUBLIC HEALTTRUCT AND/on INSTALL THE WORK H SERVICES £APPLICATION <br /> ���N CO ��WITHSA" <br /> 1722kPj4apA r M EfhAp4NMENTALHEALTH WV M"; +1.0 Aug' <br /> JOB ADC�lI;SSttTR APN# {GAG +�"� �„��_t sG <br /> City .3 pJ PARCEL-SIWA~ }y " <br /> /�OWNER'SNAME - iA 1YfQ4 �T - <br />( Coos11t+}I t A[roRE#$ i�k"4•'°'t-.�S e'w+„ r..: fj <br /> .TY OFV . L--J- SIf7 3 Z,--r- <br /> <Qa�m! �2}yQ f L 8 <br /> LcCI�N#us coommlo" D,CvA40,3DRE6# PHONE <br /> HNY3E RE�#�"J� q127,6 <br /> w2f�7.,q6 <br /> YE&L mr0 NEWWELL <br /> REPLACEMENT WELL ❑MONITORING WELL# - •. <br /> ;)-'Ili <br /> ��''••�� TT'--}f - L�'•fL OTHER <br /> -� L-.L <br /> INSTALLATION -_L..T-:YYELLSYSTEM R'UPAfR. Q CROSSCONNECTREPANT. .. LL Vi�P[tRfJiRACTgNWEL!#-- " <br /> ! " <br /> 0/ 017. <br /> I_I TNow©R+P+M Tf.P: DEPT"PUMP SET I•T FIRST WATER CEVEL O: <br /> fTYPE,t)F PUMPf t--#i <br /> E3 OUTAr-oERVICE.WEtt. E]:oEOPHYBICAL WELL#`'. ....• - SQIL BanlNd --L <br /> �yy : <br /> LJ bESTRtfCTit?M! _. vmc— <br /> INTENDED URS-6 1�T�TyiP£pF WEl1 CpNSI-XI ON SPECIFICATfONS ' <br /> tJ INDUSTRIAL El OPEN BOTTOM MIA A <br /> OIA,OF;�I 'ENSC fON j w+1 f� IMA.OF CONDUCTOR CASNNO <br /> D DOMEBTIC/MUVATE CIORAVEL PACK/91ZE �t O <br /> :TYPE OF CASINO/SSTEELfhvc Er, DW OF WELL CANIND_: <br /> PUBLIC/MUNICIPAL C1 DMVEN <br /> �'�! dEPTN OF GROUT SEAL. �t SPECIFICATION A ' <br /> 0 IN AISATiONIAG OTHER k�TVo&j GROUT'SEAL;INSTALLED.BY_-�}�1L _� � GROUT CATIO NAME <br /> E---- <br /> MOMTOAMtS 1 i GROUT MAL PUMPED:J4Y. ❑Na .CONCRETE PEDESTAL BY ORIf1ER:CT Yw <br /> •� APPROX_DE.PTN_akrm -C*~ taT-Of <br /> LOOKING CHESTER BOXISTOVE PtPE�� JVIA <br /> -�-- S: <br /> PROPOSED:CONSIVIUCTIONIMLLINO METHOD: MUD ROTARY,���^AIR ROTARY AUCER SABLE 07HEft <br /> I NIEREBY CERTIFY THAT I HAVE PREPARED TIOB APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE tAWS,AND RULES AND <br /> REGIR.A me OF THE SAN JOAOUIN COUNTY.}HOME OWNER OR LICENSFD AGENT'S:SIGNAtURE CETTTIFtES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOPK FON W►ICH <br /> VMS PERMIT MISCUED,I_'91LALL_NO.EMtPLOYPERSONG SUBJECT:TO WORKMAN'S COMPENSATION.LAWS OF CALIFORNIA.' CONTRACTOR'S HNWNQ:ORSVB-c ONTRACTIKT:SIGNATUr&GElRfF1E'6 <br /> THE FOLLOWING: "f:CERTIFY THAT UL THE PERFORMANCE OF THE WORK-FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS:SUBJECT TO WOROWAWS COMPENSATION-LAWe'�OE <br /> GAtJFOt#NI THE AFPUCATET MTUST CALL 34 HOURS.IN ADVANCE FOR ALL REQUIRED INSPE^1TOH#AT frW140*44". COMPLETE ORAVANO AT LOWER AREA:-PROVIDED. <br /> el#ned}L � T yet ' TltlsllllfIG � �(L�I�I <br /> PLOT PLAN ID,ew.io Soots)$o■ta,; .to J_ # <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY,. � 4. LOCATION OF HOUSE SEWAQE OtWROSAL SYSTEM OR PRDibSED <br /> 2.OUTLINE OF THE PROPERTY.OWING,DIMENSIONS-.AND NORTH DIRECTION, .EXPANSION OF REWAOE DISPOSAL SYSTEMS. <br /> 3.O)MENStONED OVTLfNF.S AND.LOCATIONOFALL EXWrMo AND PROPOSED $. LOCATION Of WELLS VMWN-RADIUS OF ONE-HUNDRED-FIFTY FT..:. <br /> STRUCTURES,INCLVDINO COVETED AREAS SUCH AS PATIOS;DRIVEWAYS,ANO.WALKS; ON THE PROPERTY ORADJOfHfNG PROPERTY, <br /> ....3. ............ „y,.,... .., <br /> Gu12s <br /> : I <br /> re <br /> I°I6 .....a....:. ..... . <br /> v <br /> • t <br /> rrA1FPMimCP � -+c..+,L.ir.:.. •. '. -•. : ... ....!.. ...... +5,.+..:...,.•ry <br />�..,. �. ,". b•�:. .i:.�,.,. ,.,a-•: ..`�.�'•aRbYYi•••.!•�6w*.�:a,'"gL.�rQy•'w""• _ <br /> ?•• <br /> ., b.. , - <br /> • <br /> i <br /> • .... < n. .. . . .. <br /> • :gin i.:'.i'.�..... y.. r. <br /> r. <br /> •i <br /> .�w.K <br /> • <br /> v <br /> j <br /> • r <br />�. $. y+ s '3L9'.L,.T. 2. T7EtAKRTNII�ftt LME'SY'f4L:T'� <br /> ApPBertlon Avo ptad <br /> OtotA Impmom By .bots Ptxnp,Inopsetlon Sy,. Vol, <br /> Dooln/atken,Trnpalllon Ry. Paw . <br /> ACCO UNTING:ONLY: AW:. FAC#' <br /> PE CODES FEE INFO AMOUNT REMITTEE cH K# ASH RECEIVED NY DATE DONAIT/iE1TVICE:REOUEST NL*ARFR INVOICE <br /> Pub.Health Sefv.•Bnvir6;:.173(31". y <br />