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- --' _ _- - APPLICATION FOR WELLIPUMP PERMIT <br /> SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 391,446 N.SAN JOAQUIN ST, STOCATON,CA 96201388 <br /> (2091488-3429 <br /> BOLREFUNOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICaa,alaw le TriPOuml <br /> AFaotic8tion is here by made to the Sap Jeaptin Canty for a permit to Cg tract and/or install the work described. This awtication is <br /> made In cOplience with Sen Jopuin Canty Devatoorent Ti le, CMpter 9-1115.$ aN the Stan4rda of Sen JoeWin Cotnty PWLfc Health <br /> Services, Enwiromenul Nt^ea(l nth D1ivisioont.}�st o(D .� tK—�)L(r, <br /> Jab Address/or APHN �Yt�W —// 1,,,,,,t,,�LCt7— City T... Parcel <br /> Ower's Name t)S A Aad&i vsAdtlresa�'�M run StIlAn P,l. 1-064,. phone Ii <br /> ht 1 <br /> Contractor Q.0 Q '' e� Address /�J�Dt OI/F L2 /��N1#?Q'l tic/ --- Phare t7/(z3�' n-fit <br /> Sub Contractor L 1/L II!`C/ Address IMCYJI'AOQ f'0. L(cY����'C��'+� Phone <br /> TYPE OF VELL/POMP: �❑y MEV TELL ❑ REPLACEMENT HELL ❑ MONITORING 6ELL ! ❑ OTHER <br /> .yam DESTIUUCTid D DUY-OF-SERVICE WELL D GEOPHYSICAL YELL R ❑ SOIL BORING <br /> D INSTALLATION D UELL SYSTEM REPAIR U CROSSCONNECT REPAIR D VAPOR EXTRACTION WCLL Al <br /> D New D Repair M.P. DEPTH NNP SET FT. FIRST WATER LEVEL_ <br /> (TYPE OF NNP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS II <br /> l IWUSTRIAL D OPEN BOTTOM DIA. OF YELL EXUVATIN UU+b 1101 Y0 DIA. OF CONDUCTOR CASING <br /> D DOPSTIC/PRIVATE 13 GRAVEL PACX/Sl2E_ TYPE OF USING/STEEL/PVC SSI-rim( DIA. Of WELL USING III`/F <br /> D PUBLIC/MUNICIPAL U DRIVEN DEPTH OF GROAT SUL Lja+>~nn yes SPECIFICATION <br /> D IRRIWTIOH/AG D OTHER GROUT SEAL INSTALLED By GROUT BRAND NAPE — <br /> (I MOMITMINGr/_�// GRWT SEAL TOPPED: U yet U Mo CONCRETE PEDESTAL BY OR I LLER: [I Yes D NO <br /> APPROX.DEPTH '4 W LOCKING CHESTER RON/]IOV! PIP! <br /> pnoPOSEO CONSTRUCTIONIIIALLIAll MEITHOCt FIJI ROTART�AIR ROTARY_AuGER_CARLE_�,,OTHER_ C <br /> t b z 1",to(0.�UYt °lona that dw or Aj D or `tb� <br /> I hereby cerci FY Ihh a sperm mss eFpllcetnon and that the work w 11 be done in ac r nCe with San J apJ Cca t —Ty tvrces. <br /> State Laws, and Rules and RaaJlatiow of the Sal Jospuin Canty. Hama owner or Heaved agent's 91gneture certifies the follwitp: "1 <br /> certify that in the pertorvrrce Of the work for which this pewit Is i]sucd, I shalt not eaploy grsom sabject t0" M K'S COMPENSATION <br /> Laws of California.' Contractor's hiring or 116-contractiM signature certifies the follwing: " I certify that in the perforMwtce <br /> of the.,it for which this persalt is (nand, I shall mptay person.t jact to UORUMN•S COMPENSATION taws of California." THEAPPDCAAT <br /> MUST CALL 244 HOURS IN ADVANCE FOR ALL IMBED INSPECTIONS AT(208)4SL34]S. Colplete drawing at <br /> lower are. Provided. <br /> si9rud % hl Y Titte <br /> —� PLOT PUN (Draw to Scale) Scale" to <br /> 1. Naaws of streets or rands, nearest To or bandirq the property. A. Location of hone swage disposal syetee or <br /> 2. OL,tine of the property, giving diaetviav ad North direction. proposed a.,weRion of a.,.disposal tvateen. <br /> 3. Dimensioned wtlines aml Location of it catatirlp end proposed S. Location of weite within radius of 150 ft. on <br /> 9[rVCI VFQa• nctudng coveed ea stirarach as Pan.tios, drivwe the property or ed joining property. <br /> eId walk]. <br /> 7771-T17- <br /> "I <br /> DEPART NOT USE ONLY ' <br /> Det. Are. <br /> APPNcetlon Accepted By <br /> Grwt Inspection By Dete PUq Impaction By Date_ <br /> DestrVction Iropeetim BY Date �. maenta: . <br /> ACCaUIMNO ONLY: AIDS FACS ' <br /> PE CODES FEE INFO AMOUNT AE>tTTO CNECXAG9N RECEIVED 8Y DATE PERMITOIERVICE REQUEST NUMBER INVOICE <br />