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(2091 4883420 PERMET SERVICE <br /> NON REFUNDABLE PERMIT EXPIRES I YEAR FROM 0WASQF4 16 PH Lis 22 <br /> ICempNu in TripBraL) <br /> AFRICATION IS HERE BY MAGE TO THE SAN JOAOUIN COUNTY FOR A FEWIT TO CONSTRUCT ANOOR IN6TALL THE WORL DEeCPoBED.THIS APPl1CATON I6 MADE IN COMPLIANCE WTM SAN <br /> JOAQUIN COUNTY DE !R&ENT�TRIE CC E�FB 1✓J I mDTHE�V IPSO O F SAN JOAGUCmCOU a H1 H SERVOES.E MNMENTAL HEALTH fie <br /> JJ PPRCEL mzEl NI <br /> OWNEW RE58/OR_ALPN/�IC $ isiv ...Fo ooc goo, �L/ltvl gpNE I (D <br /> OWNER'BNMI{EJIAJ'�'Y[VI.11..7�!VT✓T,G�rI/ yO�1/l�� Y1 LII-`T'/L. y •( IEA �\ <br /> IEMITI)�M,-I'Y�✓efl. "'/T^'1�/ l'1� ADOPEs6 ZO�il YETI W'J ISJ IKI R10NEf Uw 17'w <br /> SUB CONTRACTOR�1/I.Y'N'✓ �r�gamn <br /> ^ ` 1� ADOIE661�1/1GuI'/V-.pLYYAW��/ LIC/ �aZD PIbNfI •Z�'� I <br /> TYPE Of VhWPUMP: NEW WFLL C REPLACEMENT WELL /y MONROWHOWELLIM/V-7�U,L��� tq ❑ OTHER <br /> C INBT=MN C WELL SYSTEM REPMR ,C CROSSCONNECT REPAIR MW C VAPOR ExTRKT10N W o J <br /> C N.W C H r N.P. DEM PUMP SET--FT. FIRST WATER IEVFi 0 <br /> DYPE OF Mmm ❑ ON-0RSERWE WELL C GEOPHYSICAL WFLL A ❑ SOIL SORNG B <br /> ❑DESTRUCTION' <br /> IHTMOED ULE TYPE OF WML A <br /> CONSTRWTR,N IP IRCATIOTY <br /> ❑ L CA <br /> INDUSTRIAL C OPEN BOTTOM <br /> DIA.OF WELL IXCAVATON dA.OF CONDUCTOR CA-1 ' D <br /> C WIAESTICMSVATE ❑GMVEL PACxmIZf " TYPE OF CASINw6TEELIPVC dA.OF YIEISINO I' 0 <br /> ❑ PUBUCIMUNOIPAL ❑DRIVEN <br /> OEM OF GROUT SEAL I V SPECSRCAT 3 R <br /> C IRWGATIONIAG ❑OTHER GROUT SEAL INISTM BY STOUT BRAND NAME E <br /> MONRORINO GMN SEAL PUMPED: 13 Y. 11 CONCRETE R1lESTAL SY DRILLER:Cy-. ❑Ne S <br /> APPRox.ovM <br /> �S l LOCKING CHESTER SOWSTOVE RIE S <br /> ROM18m co" METOD: MUO NTMY AIR RpTA11V AVGfTI CASLE OTHffl <br /> I HE Y CERTIFY THAT 1 HAVE PREPARED THI6 APRICATION AND THAT THE WOR(WILL SE GONE IN MCOMO E YATH 8AN JOAMM COUNTY OMNA CVC STATE EAWB.AND MILES AND <br /> M:GUIATION80FTHESANAAWIN000MY. NOMEOMMORIICMSEDAOEN'SMGN WMCENIRESTNEFOIIDWING:'I CETRIFY TIUTIN THE PEIiOPMAMCE OFTHE WORE PoR W111CH <br /> THIS FENMRlai5 m.ISHALLNOTEMRDYPF.R60N8SUWECTTOWORWM.S COMPFR{ATOM UWS OF CALIFORMA.' CONTRACTORS MING OR W ONTR CTNG SIGNATURE CERTIFIES <br /> THE FOLLOWING; •I CEM,THAT IN THE PERFOMANCE OF THE WORK FDR WHICH THIS PETINT 18188Um. 6NALL FMPmY PERSONS SU6IECT TO WORWAN'S COMMNSATON"M OF <br /> M CA m 1A. {pp�Yn ANT IWT CALL M HOIN IN ADVANCE FOR ALL REOWW IN AT 13�1A =- COMRETE ORAWINO AT ONFT APPA FROVIM. <br /> Ske.f x� <br /> PIDT RAN lwwv m SerMl' .��'Ie <br /> 1. NMIES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE d WST1 SYSTEM OR PIpPoBED <br /> 3. OUTLINE OF THE RgPE RY.GMNG DIMEN6gNS AND NORTH MRER N. IX A WON Of SEWAGE g INBAL S O FON <br /> ]. MMENWNED OUTLINES MO LOCATION OF ALL Ex16TNG AHO PROPOSED S. LOCATgN OFFTY O ADJOINING <br /> IND OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATMS,DMVEWA�Y,SS.`.000WM SS.,} ON THE PIOPEINY OR A./J�IN,N,G PNOFERTY. <br /> wt�l Ips � <br /> i <br /> OEpW.FR ,EONLY l HAJUry A <br /> Apdk+<bn A>eer.a BY <br /> on. wmo I..o«:�o�ar Or <br /> c,wn IIsp.GiNn <br /> o..I„rnee Ioecvan eY <br /> comm <br />