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APPLICATIpNFOR WELUPUMP M <br /> ENVIR <br /> ti SCOUNTY PER <br /> PUBLIC HEALTH S <br /> ENVIRONMENTAL HEALTH DIVISIO CES <br /> 304 EAST WEBER AVENUE, STOCKY <br /> (209) 4"-3420 ON, CA 95202 <br /> 'AQUIAPPLICATION IS ITER BY NOR'REFUNDABLE PEp \ V <br /> MADE To n1E s MIT EXPIRES 1 YEAR FROM R \\ <br /> JOADUIN COUNTY DEyELO AN JOAOUIN COU LCompMtt In irIpTNA1.1 ATE ISSUER <br /> PMEM TRIE,'CHAPFEfl R- NTY FOR A PERMIT TO CO <br /> JOB ADDS E68/DS APNI 1116.3 AND TIIE NBTRUCT ANDro <br /> O STANDARDS OF VAN R COUNTY PUS THE We DE6CRmE0.TII <br /> �Q �6 /��'.Jrol,� JOAOUIN COUNTY ppgLIC HEALTI/SED ICEQ ENVIRONMENTAL N 16 M <br /> OWNEfl'e NAME O/ D '"O aPc) �-ruADE IN COMPLIANCE <br /> 1 lc..,.(Jfb DITY C)/ / HEALTH DIVISION. X11 SAN <br /> CONTRACTOR D� Y9pV q'i <br /> ADGRE6B / /eZ F r, PARCEL SIZEJAPNtSUN p <br /> CONTRACTOR <br /> �S!( SQ lQ/ ADDRESS PHONE I /0 <br /> TYPE OF W E_ S>< LICF J e yJ 00 <br /> ELl/PUMP ADDRESS y 'L RL^y, C' LLC��%IONS <br /> - O NEW wEtLO <br /> -6363 — <br /> ❑ INSTALUTION REPLACEMENT WELL ❑ MONNORING %TONE ' ys6•Y8 <br /> -�— New WELL SYSTEM REPAIR 1-� WELL IOTIIER�— <br /> HVPEOFPUMPI Repair <br /> ITP. LI CR088CONNECT REPAIR <br /> DEPTH PUMF bET—Tr_ 0 VAP'"EXTRACTION WELL <br /> El DESTRUCTION- EjOUT-0E-STRVICE WELLFIRST WATER LEVEL-- ✓ <br /> GEOPHYSICAL WELL R <br /> INTEN�DT= SOIL SOMNO--�-- G <br /> INDUSTRIAL TYPE OF <br /> BOTTOM CONSTgUCTIpN SPECIFICATIGNt S <br /> DOMESTIC?RIVATE 13'RAVEL PACK/SIZE DIA.OF WELL EXCAVATION <br /> PUSLIC/MVNICIPAL TYPE OF CA61N'/6TEElAeVC 1 NL({ p. <br /> DRIVEN -- DIA,OF CONDUCTORCASING v= A <br /> 11 IRRIGATION,, ❑OTHER DEPTH OF GROUT SEAL To TfYL DIA,OF WELL CASING I1 <br /> GROUT SEAL INSTALLED BY OgpT SPECIFICATION CQygQ v-T <br /> IAMONITORING _ (JRif�ev` D <br /> APPROX.DEPTH <7 U I GROUT SEAL%IMPI GROUT BRAND NAME_ IT <br /> PROPOSED CONST,VCT1ON/gnLUNO MSTNOO: MUD ROTARY CONCRETE PERI BY DMUE— E <br /> LOCKING CHESTED BOX/STOVE%vE ❑yy ''ffN/T"-II <br /> AIR ROTARY <br /> —AUGER CABLE 5 <br /> I HERESY CERTIFY THAT 1 IIAVE PREPARED THIS Ar'PUCATION AND THAT THE Wp%<WILL BE DANE IN ACCORDANCE WITH BAN JOAOVIN COUNTY OPDINANCEB,STAATEd�UI Ws,AND RULES AND <br /> OTHER N p M't; �V5/{ <br /> REGULATIONS OF TND SAN ALL NOJOAQUT <br /> COUNTY, NOME OWNER T ❑CEN6FD AOE I d BI'NATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE RRORMANC <br /> THIS PERMIT 16I68UE0,1611ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN't CoMPEFI6A11pH UWB OF CALIFOULOWIRNIA- COM <br /> RACTOR <br /> THE FOLLOWINp; •I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH Tf11H PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO US C.MAN't COMPENSATION%V <br /> W F LAWS CF <br /> CAUFORNI THE APPLICANT MVR CALL 31 HOURS IN ADVANCE FORA PERSON'S HIEING Oq SUB CONT E OF TIIE WORK FOR WITCH <br /> ALL RFOUgEp IHIN'PERM Tt AT RACTING SIGNATURE CERTIFIES <br /> BIp�yMX A`�n;L- UOSI 4011 COMPLETE DRAWING AT LOWER AREA <br /> Tills �� r'ROVIDEO. cY <br /> E. r0 Om APT- .? <br /> ROT RAM N•wv le Beelal Svb O.ro <br /> I. NAAEB OF 6TRERS OR RpAp9 NEAREST TO OR BGINpNG THE PROPERTY. lO <br /> 2. OUTLNE OF T1/E PROPERTY,GIVRM DIMENSIONS AHD NORTH DIRECTION. <br /> G. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION A. LOCATION OF MUSE SEWAGE 018POSAL SYSTEM OR PROPOSED <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,pRVEWAYS,ANO WA{K8. LOOF SEWAGE DISPOSAL VYSTEMB. <br /> t. CATION OF WELLS WTTTRN RADIUS OF ONE HUNDRED%FTY FT <br /> . ON THE PROPERTY OR ADJOINING PROPERTY, <br /> DEPARTMENT USE ONLY <br /> ApPllceSen Ap°eptM 8T <br /> 'rvol Imvatl.n BY Det. Pump Inrvasen By <br /> Du. <br /> D..e.�clle�I.reaie..Bf <br /> !/9 <br /> ACCOUNTING ONLY: AIDF <br /> FACF <br /> PE CODES FEEINFO AMOUNT REMITTED CHECKFlCASN RECEIVED■Y DATE <br /> O RRN1ITItEI1VICE REEDIEST NUMBEII INVOICE <br /> R83 Ck� C9 - - Ol5 z <br /> Pub.Health Se W,-Enviro.173(1/97) <br />