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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVE` <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 386, 904 EAST WEBER AVENUE. STOWrW CA 95201586 <br /> 1208) 481.3420 <br /> 10*10NDAILE PERMIT E NKs i TEAI FRDM DAT NO2 <br /> APPLICATION ro RNEfE ry MADE TO THE NV1 JOAOLIM RE1gMM Y Tr*ftbl - <br /> JONIRN I COUNTY H RE By MAp(r COUNTY FOR A PERMIT To CONSTRUCT AMAIN IMITALL THE WORK DMCIYEW.TRS APPLICATION ro MADE IN COMPLIANCE WTN SAN <br /> TIRE•CNAPIER 9-1115.3 AND THE KNIDARIM OF SAN JOAOUN COUNTY gIMIC HEALTH <br /> aERVIOIa.ENVIRONMENTAL HEALTH DIIRSIDN. <br /> Jos AaMEMAR API# <br /> C PARCEL MWAPN# <br /> DRINFIY.NAMI�enI P. •ICi►,_. L ivi F- <br /> w ADDIIEEE _ <br /> L_•RMTrr1YKn. r.. - _- - � Sere/@PS T PIIONEI <br /> vi <br /> ANIREM U* A ATONE <br /> «A eoNrRAeroR AIMIIEa 10123 <br /> _ pp1 uae/s�SR��4oaOg s I �L9 <br /> D4E aP W9LwY' ❑ NEW WRL ❑R3LACEMENr wEu ❑ MONITORING WELL P S.l ORER l tCIYI.G /1 fr//_1<' <br /> ❑ INWNIATDN ❑WELL ITEM REPAIR ❑ c%owcoUNEOT REPAIR ❑ VAPOR EXTRACTION WELL <br /> ❑NtAv❑R.P.0 N.P. DEPTH PIMP WT�Fr, 0 <br /> FWOF P1/MI PIRSf WATER IEVEI <br /> ❑ OUT-0OFWELL ❑ GWPNYKCAL WILL ❑ SOIL MINING <br /> WNRIFICATOM <br /> ISlI�,'II!l��s1�. <br /> ❑MMNfRK A <br /> ❑OPEN morToM MA.OF WELL E%CAVATDN DIA.OF CONDUCTOR CASINO 0 <br /> ❑Do1SGTICIPIIVATE MM❑.R GIVE..PACI(/K2E TYPE OF CAKNOTIEUPVC OW OF WELL CASMO D <br /> ❑PLISLICMMCFK <br /> JO DRIVEN DEPTH OF GROUT SEK WISCIACATION s <br /> ❑MSM,OI wm ❑oTER GRDW SEAL MIITNIEG BY GROUT MRAND NN"ffmowrmm E <br /> GRGvr EEK PIILIPEO:�V.. ❑N. HCRE'TE PEOEWAL rvDR%RERE❑Y.. ❑N. s <br /> AAROX SERV__..to fed' LodU1N0 eIEWM SOIt/ITOVE FOE s <br /> RRIOPOMe METHOD: MLro ROTAry AIR PDTAry AUGER CAKE OTNBi ai r ' <br /> I MPMWY CERTIFY THAT I HAVE PREPARED TRS APPLICATION AND THAT THE WOW NAL M DONE N ACCORDANCE WN SAN JOACIIN COUNTY OMANANCM.WATE LAWS.AND ROLM AID <br /> A MUTATIOW OF THE IAN JOAOU M COUNTY. HOME OWNER OR UCINSW AGENTS MINIATURE CERTIFIES THE IOLLOWING:h CERTIFY THAT M THE PERFORMANCE OF THE WINK PORI..AITCH <br /> TmrwawnI .IMNNLNOTENELDYPBWONSMUAJWTTOWOREIEMYOOMPEMIITMNLAWMoPCNIDNsA' CONTRACTMYSHmmoRsu&cOMRommmO"Tm CEDEES <br /> THE FOLLONA S: '1 CERTIFY THAT N THE PERFORMANCE OF THE WOR(FON WNCH THIS PERMIT IS NN ED.1 M1ALL EMPLOY PORINS WILIECT TO WORRAANTI OMOOMATON LAVA OF <br /> CAUPO MA' 7/E PPUCN T MOAT A UU M ADVANN FOR ALL R[gllllo MSPSCTMNS AT 110140-TEES. COMPLETE DMWNO AT LOWOI AREA PROVIDED. s/ <br /> PDT PLAIT Rrw b I.HH SqI. •t. <br /> 1. MAIN or I lum OR ROAD! TO OR SOUND M THE PROPERTY. 4. LOCATION OF NOUN MIRAGE ONSOML sYSrOM M PRDPOSW <br /> 1. OUTLINE OF THEP" O111NG OIERONIDN6 AND NORTH DIRECTION. "FANNON OF SEWAGE DMPOSN.SVGTGR. <br /> 3. OIelEOIo ounM I AM LOCATION OF ALL E%RING AND POPOSW S. LOCATION OF WELLS IRmRN MARIA OF ONE HUNDRED FIFTY FT. <br /> STRICTUB.NCUIOIIN COVERED AIF"SUCH N FATKW ORRVEWAYS,AND WAU(I. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> $ � 2 <br /> A \A ow ONLY <br /> x V.: <br /> APPS.MMn A.srP.M w 0.t. Ar« <br /> w.R.Yr}stlw,w '�PunP NrP..U.n w D.t. <br /> D.n.w.r.Ir.PsUar,w DM. <br /> Cm MR: <br /> ACCOUTMG ONLY: AID/ FAC# <br /> 1 <br /> PE cO RE MAT AMOUNT REMITTED CMICR#IOASH RMCEVW by OA PEMTNIMCE RA N MT NUAEI 044=1 <br /> Q [l <br /> 0000, <br /> 1 <br />