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1 <br />' 'APPUC�lTM FOSw»RP Pyr e <br /> .>-�COUNTY PUJIUC SEWN SEAS <br /> EavtaapaltFrTAr.RALTq DtYiSIg11 'PikeW 1-*STOCMIL CA <br /> �• m�t e854m 3)" 046% <br /> ygll.It ZDAVQ PWW Wn 1 ng FROM Mug= <br />' Application is here by made to the San Joaquin CxrheY for a parait to construct and/or install the wort described. This aWtfcstion is <br /> made in compliance with San Joaquin Can eveiaphharht Titte, Chapter 9-11153 and the Of San Joaquin Cashty Public Health <br /> Services, Eaviroraaental Health Division <br /> .ob Address/or APR# rZ .• • deity Parcel SizdAPNt <br /> tLr <br /> owners Naahe, JT/?�/l7t�r �2G_�_ Address Phone •' zw3� <br /> 31GY/ .// <br /> ntraetor 1/L/Qill Jlddraaa Mice ! <br />' Sub Contractor ]2 �r'i_11f AddressFOIS ^ Li� Pth Z -L 1S <br /> TYPE OF VEIL/PU MPY ,W-WW WILL 0ReviT BELL �IRIIIITCY1IiiR iiEl.Lw*11 � � ,�'OTisER Q�M"3�'9�!4 <br />' 0 DEST211CTION Cl off-OF-SERVICE YELL it GBOPRTSICAL WELL hl q <br /> 0 INSTALLATION (I ML STEM REPAIR Q CROSS-CONVECT REPAIR VAPOR WRACTIOhi YELL BJW 1:Z <br /> 0 Rehr l,l Repair N.P. DF.PTU PUMP SET Fr. FIRST VATER LEVEL_="_ <br />' jTPE of PIMP) <br /> i1��ED USE TYPE OF IRBI. CDIISTRUCTfuIt SP2C>FLtATLt1Rf go j. Is <br /> 11 l*DU5TRIAL 11 OPEN WITCH 01A- OF HELL EWAVATI;S `P)Q DUL. OF ODN =QR CASING <br />' 0 DOMESTIC/PRIVATE >CPRAVm Pmz/SIZB#�l TTPE OF cASi>iG/SrwivvC FUC+ DIA. OF WELL WHO Z A 4'r <br /> {1 PUBLIC/MUNICIPAL 0 DRIVEN 09M DF MW SEAL ria SPECIMAT1ON PV <br /> II IRRIGATION/AC El Or ORL1laT wAL IIfgTAum SY mw /RAND NAME r�a.l � <br /> >CWWITORING "y CWH SE11L PUMPEDS IKYRs 13 No CQNCRETE PEDESTAL BY DRILLER: Wfes 0 No <br /> APPROX.ODYN `_ - LOCKIHO CHESTER BOi1/STQVE PIPE �4.NTwsarats <br /> PROPOSED CoxamICT10RlmmilOId 11ECHOD: mW ROTAAY— AIR ROTARY— Auimff !L =A— <br /> I <br /> Or1iE!!_ <br /> 1 hereby certify that I have prepared this appl Cat on and that the work Witt be done in accordance with San Joaquin Carxy tlydhmmwes, <br /> State Laws, and RuLas and Rayulatsans of the San JoWin Councy. Raw owner or Licensed agent's signature certifies the faltowinp¢ "I <br /> certify that in the perforwance of the work for which this perait is issued, I shall, rat emptay persons subject to WOROMIS COMPEWATICH <br />' iays of Cat Ifornis.n Contractor's hiring or Wo-contracting signature certifies the fottowinsh • I certify that in the performance <br /> ar the -tork for vhich this permit is iaswd, I sl*alt eaploy persons subject to WCRW MJS COMPO ATION Laws of Catiforthha." T)IFAPFUCRRT <br /> BUST CAU 1:4 NO IN ADVANCE FOR AEWMSD OW, NO ATM 44-UU, Camptets drawing at Lacer arta provided. <br /> S i fined xTit! i'o0 to <br /> I <br /> DUAWW"an'Ry- <br /> 1 <br /> IApplication Accepted By Dat, u ' •! Ana+ <br /> Grout inspection By Date Pump Inspection By Date <br /> Destruction Inhspeeticn By Data Coaaerts: 6,ha'A � <br /> 1CCOUMTDN6 ONLY: AIDS FACR <br /> PE CODES FEE WO ApDi Xr MfDYrEO CR311 RICOM 1Y DATE PERMUM= REDDEST SUMER love= 1 <br /> 1 <br /> HV6 t- i t Rye t-P i-� <br />