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E=,L3-1 99.7 2:25PM FROM P. l <br /> APPLICATION FOR WRLIPUMP PERMIT <br /> 4AX. JOAOU1N COUNTY PUBLIC HEALTH SERVICES. <br /> ENVIRONMENTAL HEALTH 01VISIGN <br /> P.O. Box 3M SIX EAST WRR AVENUE.STO <br /> EBCKTON, CA 9E201388 <br /> (209) 468.3420 <br /> NOW-REFURDARCE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> lCPmpirlr In TAnScatii <br /> APPLICATIOM it 11M OY MADE TO TWE$AN JOAOUIN COUNTY FOR A PEMAT TO CONS'rW.XT AI1DIpIl rNSTAI.L THE WORK DFBCRIPEO.TLIT9 AVPLICATION Sit UADE IN COM--FAN � <br /> CE WTTIE SnN <br /> JOAOUW COUnTT'Y OEyELOPt1EI+fY�TIy7'Lf.Ci1ARrEq 9-7115.3 AHp THE BTAIiDAAryq OF 9Ale JOAmnu GOUWTY pL18[1C HEALTri SERVSCEd.ENvfwnuE*frAl 14Eal7x plve6+plJ, <br /> J08 AODRESS/OR APNI C.+f•/ /+ /�l�i��0 - 1�'`�I4 Mf 4!rrv.� �7�.�. l PSA/PCEL Sf JADNA <br /> OVIWER's kAM /P��] _'#%7�-/��) /,iA ACWAW-96 IG++ <br /> CONTRACTOR fT Y W tA�YFG ARDRESB i 'Q.�O VT'� r [JCtYP1lO�f s�7IOFV <br /> FLls CONTPACTOR ADrlfec,SB�_ U'C1 R10Nfj/ <br /> rYPE O-F.WELt1PUMP: ❑ ftSW V tU l_r RFnIACr.EKT",ax OrurOa1147 1NELL• <br /> I❑II OTHF,R <br /> ❑ INgYALL.RTIOH ❑ WELL SYSTEM rttV^jR ❑ CRO-"ONNECT REPAIR LJ 11AAR ExTRwCTtON WELL• J <br /> (IYPF OF r'VLAPi ElH—©P-v J. 11,P. OF"H VJUP sE1' PT- FMST WATFR LEVEL r1 <br /> ❑ OUT-OF-tFTIVICE WELL ❑ OFOnfYS1CnL vvfL F © SOIL B41aNp R <br /> ❑DESTF IJcnDN- <br /> W 7CMDED USE TYPE OF WKQL COMCTROCIlON iPECIFLCATEOlIA �(� A <br /> ❑ WOUG5 MAI. ©Omll boTTOM DIA_OF VJFLl-EXCAVATION O.A.OT CONVIV TOR CASMO �I-VII` O <br /> ❑ 000Ik9TiCA.UVATE �QRM,VEL PAC><1RISE TYP[OL CAcmmntffr EIJDVC— YT11,10 G O.A.OF WELL CAgTNR �i D <br /> ❑ PUSUC/MUNcwAL ❑DFIVEN oEOTW OF C3ROLIT SEAL 4I-3 LKCTFMCATION R <br /> ❑ IRRIGATIOI/104 ❑OTN£R GROUT SEAL MgTALLED SY /jc=t 42ROUT BRAND NAME E <br /> SX MOW TORINO _ l , 00OUT SEAL,"mNO.❑T— []if**[]if** COUCRETE PEDESTAL 8Y DRILLER-❑Yr ❑Nv .T . <br /> APP"09-DEPTH (_�JL5A LOCK*4 CWCUTER IIOYI.VfOVE alfa S <br /> P"VOCED CO"$TRUcnOMMffV ftG METHOD- tg(M ROTARY AMR MOT"" AL"m CAbt�_ OTHER <br /> E 0MSV CEWWV THAT r HAW PREVAREQ TIMP AO"JCATffja P.0 THAT TWE WOWK V^LL RF 0014%iN AC=910ANCE%NTN 4AN JOAOUIH COV O.tpINANCC9-STATE t1V,8.ADO AVEES AMp <br /> MGULATTONA OF"M SAN JOAQUIN C0kMrTT. NOW 0%4W..R OR LICEMSSo A(IEW't ftm ATUNG rERTIFI(6�TILE FOLLOVtIIMO:-f CERTriY THAT iN TNf PERrOIaI_wr Or Tui . %tu FOR w1AND <br /> TWIA PEl+aarT to 188VED,L SHAI-1 MOT EMPLOY PErIRONS 6USJFC7 70 WORI[EAaYt[011FPEin/ATpR L,IMrB pfl CALIGp{W1A: COMTRACTOR'e HIRRIO OR 9tjSC01/TILACTINO SICUATVAE CERTIFIES <br /> TME FOLLOWIMO; 'r CtMIFY THAT 111 TItE PERFORMANCE OF Tile V40$w rOR%VFIICH TInS PESIdjT It LASUED.1 SHALL rL"%*T r'EftM-S SV9JECT TO WORKMAN'S COUVENAArOM LAWS OF <br /> CALIFORNIA,' THE NT IiWLT LL u NONRA 1R AOVAM[f tOR ALL kEOtaleTp MAPKCTIOMt AT rlOAf AGt-a.I,-It- CCu1tZrTE pRAwIWp AT LOWER ARTA NtTVTDET7. <br /> TRI. 7-�^0... 3--9-c�c <br /> MOT RAN 9*-1e 8n.1.1 P..1. 'M�� <br /> i. NAMFf Or STREETS OR ROAOR NEAREST TO OR @OVML11N11 THE"I*" 1'Y. t <br /> LOCATIpM Df W1lSE SEWAGE OISPOtIAI tYBTEM DR 1T+DT+pEED <br /> 2. OUTUINE Or-TME POVERTY.ONWO E0AENRIONS AND NORTH DMCMN. EYVANt1Oe1 OF 9EWADE W81 OGAL SYSTEUS. <br /> 7. Df"ENSIONEO OVTLINF9 AND IOCAT1010 OF ALL EXIVMM AND ARJMyEp •_ LOCATIOW OF WELLS WITIHPI RAOMS OF ONE WJwCItEO F1FTV rT. <br /> STRUCTUnES.INCLVOW0 COVETED AREA&EVCH Aa PATIOS.VfgV£WAYy,ANO WALKS_ ON THE PROPERTY OR AOJOWWO FMPERTY. <br /> C 0 <br /> p y <br /> o- <br /> VWARTMIEHT UtE ONLY <br /> AmW6-0. Ae 114 � 0 Ibr <br /> O.vu1 I.,.ot.�.bT A.er "V I'm-y4M.0Y D►I+ <br /> Ow.Inn+fv�1.�e�Ily.8T pwr <br /> Cwv.. <br /> ACCOVNTnrO <br /> ONLY: A1Dr PACs <br /> .E CODES GEE TWO AMOUNT REWYTEO CIIEeKSICAeN RLG111VED bTDA PtFULA T1A1@IMC£REOkKXT IItSWOER INVOICE <br /> lq5 gi 9 <br /> 1 <br /> Putr,Hsal$t Sam-EnvIrp.173(31W <br /> Post-it11 Fax Note 7871 DATA (� -7 A of t <br /> TpZ From D 0 <br /> COIDOpa CO.RAS EH5't <br />