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APPLICATION FOR WELUPUMP PERMI' <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SL <br /> I AS <br /> P.O. ENVIRONMENTAL UIS _ <br /> EASTHEALTH DIVISION <br /> CA 95201388 RECE VEJ <br /> (2091 488-3420 FEB C <br /> SANNON-REFUNDABLE PERMIT EIIPIRES 1 TEAR FROM DATE ISSUED PUB IC P4r.o .'T ,' <br /> APPLICATION It MERE BY MAGE TO THE eAJ!UOAIXlI6 COUNTY FOR A PEIIIAR TO CONSTIIUCT ANOXIANSTALL THE WONL DEKRESEp.THIS APRRCATgN Is MADE <br /> M F <br /> AAOVIN COUNTY OFV[LOPMENT TITLE.CHAPTER III, TO <br /> 115.3 AND THE STMDApS OF JOAWW COUNTY MOM HEALTH SERVICES, ,N,,HONMEMAL HEALTH ORRMON. 'msµ <br /> JOe ADD1E[WR APHR I - � /ZI O3 eo TTG f <br /> DWNE11'2 NAPE (� I //99 PARCEL ECWApW <br /> Ork_I'Y�' �C':'\ YaQ Lli ARS / ADDRF [ 1 <br /> mc. 3/ QW > <br /> CONTRACTDA I1 VI ADDIEe[/7- ! /R • v PHONE• <br /> LICs <br /> nlQ MpME Ic OD <br /> sue COMTRAOR ) ADDRESS <br /> CP•. s� LLeE S ST7 <br /> •���((( �FMOM[ 6. 274 <br /> TYPE pF�),Ig.Mi ❑ NEW WELL ❑ M[NT WELL MOMTORNO WILL I �Z� ❑ OTHER <br /> 1:1NsTALLATION C3 SYSTEM MMI CIO{SLONNER KPAN ❑ VAmm ErrFACTION WELL P <br /> 13 Nw 13ILIPw, H!. <br /> OEPTL MMP SET�FT. � FIRST WATER LEVEL <br /> RIFE Of FVMF) O <br /> ❑ t ,.{ERVICE WELL ❑ O,o NYHCAL WELLI ❑ WIL oc RNO <br /> s <br /> D pEtTR1CTION: <br /> INTp O LAE Tyr*OF WELL CONSTRUCTION tP[CFRCA ONt <br /> 11 *MsTaiA ❑OPEN DOTTOM� ,I'2 ' � pp dA.OF WELL EXCAVATION <br /> M �I <br /> 13OOMEeTKR9{VATE 11 GRAVEL PACK dA.OF CONDVCTDR CASINO <br /> _ TYPE Of CMNOIETEEINVC DIA.OF WELL C//ApNO� -- O n <br /> 11 PVeLICMIINICIPAL D DRIVENDEPTH OF GROUT SEAL (i — S - r/' <br /> ❑ {E[OATM"IAO DOTHER onom SEAL NSTALLEp <br /> OROIJT eIIAERD NAA1E IIn�tt E <br /> ® MONROnND opvr EFAL FVMRD DY. ❑NP CONCRETE PEOERK EY DRRIER: Y. 13,% s <br /> APPROX.DEPTH 30 A O'Y LOCXNO CHESRR WXATOW PIPE �E <br /> S TI. <br /> IROROfm CORSTRlCT10M/pRLMO METHOD: MUD piA11Y AIR ROTARY AUGER 1� C"Ll OTM[R <br /> 1 NAEIY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL IN OOIIE N ACCOpANCE WITH SAN MAOUN COUNTY OIIDINANCEs•Sr ATE UWt.AND RULES AND <br /> REOUTATIONe OF THE{AN AADUN COUNTY. HOME OWNER OR UCW/FD AGENT-8 SIGNATURE CERTIFES NNE FOLLOWNO:•I CERTIFY THAT M THE RE1E01\.IAHOE OF THE WOISL FOR WIRCN <br /> THIS PERMIT M ISSUED,1 WALL NOT EMPLOY PERSONS SUWECT TO WORIWAR's CWPEMSATION LAM OF THEMUOVA CONTIV.CTOR•S HL\Pq OR ML A,CT F HE W, IIS CFI~CH <br /> THE FOLLOWING: I CERTIFY THAT IN THE PE/EO,R,IN E OF THE NOI\C FOR WHICH TNIt PERMIT IS ASUED,1 WALL EMPLOY PERSON\JWXCT TO WORIWAN•t CLNHPlR\ATON LAWS OF <br /> CMIFOIIMA' II APPVCANT MWT CALL A•MOW H ADVANCE FOR ALL M I<TgM AT I] S)`H`P t01 COMPLETE DM1W W AT LOW."AREA PROVIDED. <br /> ROT RAN IDlFW b NPN)YW 'b V <br /> t. MANTES OF ETHEET OR ROADS NEAIHO ENE TO OR lO D NOR THE ECTION. 4. LOCATION OF HOUSE SEWAGE dYOSAL WrrFM OR PIIDPOM <br /> L. DUTUHE OF THE FR NES ANrY, LOCA DIMENSIONS AND M AN dRECT " EXPANSION OF SEWAGE dSFO/AL SYSTEMS <br /> ] TMCTVMSD OCUM01i AND LOCATION OF ALL EJLIRINO AND PpPOSEO <br /> STRUCTVRt INCWpHO COVERED A11EASEUCN PATIO*.DIOWWAYE AND WALKIL UNDIEO FIFTY FT. <br /> ION OF NEW WIT/11N RADRIt OF ONE M <br /> ON THE PpPFIRV OR ADJOIMHO PROPERTY. <br /> .... .. ..4...._:_. <br /> ._L .... i ... <br /> ..........5 <br /> .._. ..-a...... .....o...a <br /> 'B ... <br /> .: ... ....:..... ......... ......:......: ..... .::: <br /> _...i......i <br /> :......4.....�....s4 <br /> l <br /> DEPARTMENT WE ONLY Q <br /> APFA�DH.Aaslr er <br /> D.wA N...HIwI erg/ D... PLnP II.P..D.n tT <br /> D�rutMn N.PrD.n er T ab <br /> ! ` <br /> ACCOU TINO ONLY'. AIDR FACT <br /> RCOOEA RR INFO AMOUNT RPgIrro CHECILFICYN An \Y DATE PE 11ERWC[R[OUEJT NUNIDSI INVOICE <br /> 13501kuwz 4 z /TG O o 8 03 <br /> i <br /> z ' d Tv : OT 96/10/20 W02j <br />