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2 0 0 _ — <br /> 3 H d -1 U i O i *x yyEl„LlSic' azwacw m 1 <br /> -" APPLICATION FOR rumr rexme� ,� <br /> S&-�DAaUIN COUNTY PUBLIC HEALTH SERVICES n �p�ecQ WC'�� <br /> ENvIROMMENTAL WEALTH DIAS10N -ttJy <br /> P O $OX 369. 946 N. SAN JCAIIUIN ST. sUCXTON. CA 962131.329 <br /> (209) 4684WO 1 o c"&Vts . <br /> rDN 11oASIJe PERMIT CM ;S 1 YEAR EMS DATE ISSU <br /> g 1.13 M Tr0mal on_ <br /> Application is here by wade to the San Joaquin C:unty for aperMit Cha ter construct-11 3 and oche Standards f San r instalL the work eJoaqubin�County his aP"L ictHe•lth <br /> mode in coeptiance with San Joaquin County Dere -Darn r P <br /> services, Environmental Health Division. n, <br /> � �M <br /> G« rpp'}" LII FA• _ C{ty�YJIGV i . Percel Size/APN <br /> Job Addresa/or APu <br /> /� 2 PAt1 Address •0, Phone # 0 6b j <br /> OwneN s Name l.yS►O INl6Q- �y . <br /> ,�1 Lic? 4-91 k0 3 Phone 1#H1S ES 0860 <br /> ContractorTaci�'L M YLV6roN�1lR:l f Address <br /> lit# Phone Al �` 460 <br /> Sub Contractor i Address7] �Iorcicla���F✓�� <br /> TYPE OF WELL/"P: NEW WELL f� ,TCaLACEtiENT WELL �MONfTORIHG WELL * 1N * (o d OTHER <br /> a M�►�1s <br /> ❑ DESTRUCTION a DUT-OF-SERVICE WELL ❑` GEOPeTSICAl. WELL SOIL WRING <br /> a INSTALLATION ❑ WELL SYSTEM REPAIR a CROSS-CONNECT REPAIR (3 VAPOR EXTRACTION WELL <br /> .. _ ❑ New ❑ Repair N.P. DEPTH PUMP SET_^,r_,_FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> JMT DEO USE TYTE of WEII CONSTSUCTION SPECIFICATIONS u <br /> rr DtA. OF CONDUCTOR CASING N p <br /> (3 INDUSTRIAL 13 OPEN BOTTOM DIA. OF WELL EXCAVATION b_.�_ <br /> ❑ DOMESTIC/PRIVATE tI GRAVEL PAWSIZEjlv— ��`�of�GRONU�SE�C 5 I s� SPECIPfCATIONF WELL �SING -V61S,A" a <br /> C3 PUBLIC/MUNICIPAL C3 DRIVEN <br /> C7 IRRIGATION/AG C3 OTHER G,TOUT SEAL INSTALLED BY GRCAJT BRAND NAHE <br /> MONITORING GACuf 'SEAL Pu"Pft:x Yes a No CONCRETE PEOCSTAL BY DRILLER: ❑ Yes y No ulh <br /> APPROX.OEPTN 3Or„ LOCKING CHESTER BOX/STOVE PIPE MorriRosh-kra�ic ram, osh movrtkcd VXILCI JM <br /> PROPOSED CONSTRUCTIONMAILLLNG NUMOD: *m ROTAAY_ AIR ROTARY, AUGER CABLE_, OTNER.„^_ <br /> oaquin County Ordinances, <br /> I hereby certify that I have epared this appt:carion and that the work will be dons in accordance with San J <br /> pr <br /> State Lays, and Rules and Regutations of the San Joaquin County. Name owner or licensed agent's signature certifies the following: "t <br /> OM <br /> certify that in the petforamnee of the+Toric for>hich this Permit is issued, I shat( not.emp(oy persons subject co at in <br /> CCMr4or=ENSAT ce <br /> Laws of Catifornia.0 Contractor's hiring or sub-contracting signature certifies the following: " t certify that in the performance <br /> os the work for which this permit is issued, I s1--all employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL�24MHORS,IN AOYANCt FUB AEO IhLa IMECTIONS AT [20414W2422. Complete drawing at lower area provided. <br /> Signa/ X � TittaI�� � Date <br /> I Ll <br /> DEPARTU81T USE ONLY <br /> Application Accepted Sy oats Area <br /> Grout Inspection By nate Pump tnspection By Date <br /> Oaaerweian inepoeti� ey Data Comments: <br /> ACCOUNTING ONLY: AIDS FACX <br /> PE CODES FEE INFO ANIOUNf ADAMED CiECX/ICASN RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> I <br /> 4 <br />