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APrL1 N FOR WELL�UMP MMIT <br /> SAN JCAOU UNIT►USLIC HEALTH SERVICES PA ENT <br /> j ENtlR10SKWAL HEALTH INVISION <br /> P O 1"Sq,496 IL SAN JOA0UM IT,STOCKTOK CA 96201381 RECEIVED <br /> czot►41113420 JAN 0 5 ION <br /> wR•RBB "ou Muff MIMI I REAR for RATE mus' <br /> u SAN JOW',.,sU1N CtZNTY <br /> m1EfwS•Ill Trwbsw PUBLIC HEALTH SERVICES <br /> APPLICATION M HERE H DE <br /> WUTO THE MN JOAaII COUNTY FOR A FOMM TO COINTRUCT ANDM MrALL THE WOIK DE161SS®.TIIN = Ii1O(� LMC"gMfl t <br /> JOAQUIN COUNTY DEVELOPMENT TM&CHAFTM 9.1115.3 AND THE RANDAIOI OF LAN JOAQUN MINTY FINNIC HEALTH SUMCEE 8ftMNM RI;AL HEALTH O11MON. <br /> JOS AOOIEEEion. 9,3 CIM IP `',�V S,SQE/APNI <br /> Owmilm NAIJE N1 ' RHONE a 9 J <br /> AIxIIE11 a <br /> coNrRAcroll AOOIEN O UCA�23/3 <br /> PHONE.A6b—ft <br /> «I caNrRAcmR -- AooP<1s �I�„rA--�f�ii��,uv fMolE. , <br /> TYPE OP wELlwur: 0,�/IEIN WILL REPLACEMENT WELL 0 mmrown WILL a 0 arIER <br /> IQ NRALLATRON L,WELL 1v1r941IEPAIR 0 CR011•COMECT R9AM O VAPOR EiRMCTION WELL I +. <br /> 4_ !�Mw� IINdr Mr._� Do"R1M EET Z�PT. HIR WATER IEVB � Q <br /> ITYPE OF PMl1 <br /> 0 ovrOFJELWICE WELL 0 awwvfICAL WILL/ 0 EOL IROR11a S <br /> ODINTNIcrIOrc <br /> MUMMEM A <br /> 0 MOIIrIAL O oral SOTToM DIA.OF WELL EXCAVATION CIA,OF CONDUCTORCAM R D <br /> 0 OOSERI vmvATE 0 apAVIL►AcKmn TYPE OF CAKINHTMPYC DIA.OF WELL CASMN D - <br /> O PLOMM IICFAL 0 ORIvm OIFr"OF GROUT SEAL SFECFICATION R� <br /> 0 moATOIDA3 0 OTHm GROUT ZEAL MMITALIED NY GROUT MMD NAME E <br /> 0 moMrO1N1a amour DEAL RISIRR 0Y- ON. cONCIETE PmwAL MY DRRL m 0 Y- ON. a _ <br /> APRIDX omm LOCxNO CHESrM SOXATTOVE ME d <br /> FROFor CON11TINCTIONIORt1INa MI THM. SRN ROTARY AM ROTMV AUG9L_CA/1k_OTHEFL _ <br /> I WNW CERTIFY TINT I WIVE PREPARED TNN AND THAT THE WOK WILL R DONE N ACCOIOAHM WIRI RAN JOAOUN COUNTY aOM1ANCM STATE LAV^AND RIM ARO <br /> REMLATIaN OF THE GNI JOAOIII COUNTY.HOWOV1011111 OR LOOMED AOOR'S SNNATURE CORFES TIE PwxIWI I:1 CSRTFY THAT N THE POMOPWANCE OF THE WoEI FOR WHICH <br /> TNM I•YUL NOT TO Wa1MSaAN'S COMNSA f CAUPD NUL"CONTINA OR'S OMNIS OR SIILONMACTEM IMMATURE C6ITMES <br /> THE OF T11E WOIL FOR WMCM NIS I HALL OFIOY FONoNS SUILECT To WOIOMN'S OOSFONATION LAVA Of <br /> AT Sl<COSFIET!DIIAYFMIS AT IaVYOI AHA PIOVOECD. QC <br /> %j <br /> Syw x TNI. <br /> + PLOT P.Drw M Sall t..R. afIr <br /> T.MMES R <br /> OF WITS OR ROADS NEAIEW TO OR IOUNOSN THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE aUOSAL GMM OR PROPOSED <br /> 2.OUTLINE OF THE PROPMTY,Qr~OMARISIDNS AND NORM OGECTXPL EXPAHMON OF RWAQ 0I410401AL 1vSTEIM <br /> L;==AND AND LOCATION OF ALL EXOTURS AND PROPOS® S.LOCATION OF WELLS W ITM MOM OF ONE HUNDA D FIFTY FT. <br /> iTPUCTIME<MICElISI CA'VOED AHEM OWN AS M71M ONVEWAVL APO WAW. 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