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❑DESTRUCTION: u -[-'AYEICAL WELL# ❑ SOIL BORING <br /> B ; <br /> PE OF WELLCONSTRUCTIONbPECI ICATIONb <br /> 1❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION A <br /> DOMESTICMRIVATE 13 GRAVEL PACK/SIZE DIA.OF CONDUCTOR CASINO <br /> TYPE OF CASINO/STEEVPVC D <br /> ❑ IRRIGAPVRUCIONIA IPAL 11 DRIVEN DECIFIIA.OF WELL CASINOD <br /> DEPTH OF GROUT SEAL SPECIFICATION <br /> y ❑ MONITORING OTHER GROUT SEAL INSTALLED BY A <br /> ❑ MONITORING I 1 GROW BRAND NAME__—_ F L <br /> OROVT SEAL PIMPED: ❑TE ❑Ne CONCRETE PEDESTAL SYOGLLER:❑Yr ❑Ne S <br /> APPROX.DEPTH_ tOCKWO CHESTER SO%/STOVE RPE S <br /> PROPOSED CONSTBUCTIONRNBLIINO METHOO: MUD ROTARY AIR ROTARYS l <br /> AUGER CABLE OTHER <br /> 1 HEREBY CERT HE S I JOA PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOADUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND (_ <br /> REGULATIONS THE SAN ALL T COUNTY. NOME OWNER O ICENSED AGENT'S SIGNATURE CEIRTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PPVOIRMµCE OF THE NIB(FOR WHICH <br /> TNI6 PERMIT I I SUED,1 SIIAIt T E OY NS SUBJECT O WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOW 1 CERTIFY T HE R ANCE OF E WORK FOR WHICH THIS PERMrT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- CA T N ADVA E FOR ALL REOURFD INSPECTIONS AT 12861 6001122, COMPLETE CMWING AT LOWER AREA PROVIDED. <br /> 3101 X TIB. Sec—TresL <br /> ON. 10/15/97 c <br /> 1. NAMES Of STREETS OR RO AREBT TO OR BOUNDING NF PRpPERTY. SPH. •le <br /> 2. OUTLINE OF THE PNOPERTY,OIVINO DIMENSIONS AND NORTH DIRECTION, b, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On P RASED <br /> S. DIMENSONED OUTUNDS AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOINING PHOPENTY, <br /> �!//+I . <br /> ... <br /> l� e <br /> r <br /> % �If <br /> lt <br /> qla- <br /> a <br /> .... <br /> G €CES P <br /> I.. <br /> .,.... .. .:....;.. o <br /> CT 2 41997 <br /> ..° <br /> saNJoaoum COUNTY, <br /> - - <br /> PUSUC HEN TH SERVICES <br /> ENVIRONMENTAL HFALTH DjVISto R <br /> DEPARTMENT USE ONLY <br /> APPIk.Ibn AeeepR.d By / �-� MY <br /> D.R. ` T <br /> Orem ImP«Sen ev .ro Pvnv Imp«Oen Sy <br /> D.R.6/ 0 <br /> Omtrmeen Imo«Oen Sy <br /> y7� /� 1 D.ee <br /> cemn,a..I. IV �i/L� M��C li�W✓� 3 �! G.eG�C/ /LSCC CB <br /> ACCOUNTING ONIY: AID# FACT <br /> PE CODES FEE INFO AMOUNT REMITTED HECK (CASH RECOPIED BY DATE <br /> IFJYMITIbFAVICE REQUEST NUMBER INVOICE <br /> Pub.Health Serv.-Enviro.173(1/97) <br />