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w uun.wvnI T ut VtLUr tRI [I1 Lt,CHAPTER 9-1]1 5.3 A ST AtoO a-q:+i!;F XAN.mADOIN COEINTV FY/BUC HEALTII SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORESS/OR APNI all{, CitK, A a_ PARCEL 91ZE/APNI a QG . <br /> OWNER'SNAMEe,-, <br /> GL ED <br /> PHONE/ 0 7- 777 C� <br /> CONTRACTOR a ,Gc�a` L EMff5 tg3 PHONE134 7�rt <br /> SUS CONTRACTOR _ADDRF49_ �— _� J���IC• PHONE <br /> TYPE OF WELL/PUMP: %HFW WELL ❑ RFPLACEME.:T V;TI I. �.I MONryOR1A4V,WF{.I L_ _ ❑ OTHER_ <br /> ❑ INSTALLATION ❑ WELL SYSTFM REPAIR ❑ C4o9S-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ <br /> � I 1 <br /> ew❑Mpeit H.P./ /01'� O£I"II PUMP SET iT. FIRST WATER LEVEL_ p <br /> (TYPE F PUMPI <br /> ❑ OUT•Or SERVICE WELL ❑ O:fuete'S{CAt WEII S ❑ SOIL BORING e <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL — mg MF n <br /> CON67RUC7PON SPEL:IFICATIONS A <br /> rl <br /> ❑ INDUSTRIAL ❑OPEN BO TTom 1V. DIA.OF WELL EXCAVA tION_ DIA.OF CONDUCTOR CAB NCO p <br /> �DOMESTICB`RIVATEGRAVEL PACK/SIZE#Tett g4AI✓,TYPF or CASIN(I/STE£1JPVC W� DIA OF WFILCASINO (y D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN Owrt,OF OROi:T SfAt� Qn _ 6I'fC.IFICATIO q <br /> ❑ IRRIOATK)NIAG ❑OTHER CROUT SEAL tNSTAIi FD BY GROUT BRAND NAME e E <br /> ❑ <br /> MONITORING ORUVT RFAi.YlIM19U'u', ON. CONCRETE PEDESTAL BY DRILLED.V.- CIN. S <br /> , ^ c <br /> APPROX.DEPTH t�l.J� LOCKING CPF.STER BOX/STOVE PIPE S <br /> PROPOSED CONSTSUCTIORIDFVIUNG METHOD: MIND ROTARV—�-4- ` _AIR M)TAR)' AUGER CABLE—_ _OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THF wow W{i RF DONT 1; ACCOROANCF WITH BAN JOAoum COUNtY ORDINANCES,STATE LAWS,AND RULES AND v\ <br /> RFGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNFR OR LIr FNSFD AOFUl'S SiGNATIJRF CFRTIFIFS THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH v: <br /> THIS PERMIT 19 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN't I.AV'JS OT CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOPK Foll WHICH TIUS F'FRF.IIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALfFORNIA.' HE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALI RFOUIRED INXPECT1ONe AT 12")464-3423, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Slp X Tiiic_ <br /> P <br /> PLOT PIAN ID.ew ro B.:eiel <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THF PROPERTY. ^� 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYBTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NOFRH DIRFCIION. EXPANSION OF SEWAGE DISPOSAL SYSTEM@. '1Ya <br /> X. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOS{D S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRl1CTVRE6,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,oNU=�'.1L%8.---�+_- ON THE PROPERTY OR ADJOINING PROPERTY. <br /> A Vv, :o <br /> 0 <br /> �n Q <br /> a - <br /> t <br /> tJ�cse <br /> ,IAN 91997 <br /> SAN JOAQUIN COUNTY <br /> PUOLIC HEALTH SERVICES <br /> IL _ — — — IRGNMEfd?FhJEALTH.pfViSl. N.......... ........... <br /> 17FPAPt+ucHT'JSE ONt Y 1 t�3 Z ' <br /> ApplbelMn AeoepteA BY_—_.._ A, <br /> 01-A hnpectlen By bels 47 Pump Inspection ByAlrf <br /> Dne <br /> Deelnietlen Impxllon By—..____ <br /> It `CommdH�:�' <br /> t6 12� ,!' _0..,. . <br /> AccouNnNo ONE _� n1D,F <br />