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d.� <br /> APPLICATION FOR VIEWPUMP PERMIT <br /> "`4AN JOAOUIN COUNTY PURLIC IIEALTN SERVICES~ <br /> ENVIRONMENTAL HEALTH DIVISION ' <br /> P.O. BOX 388, 804 EAST WEBER AVENUE, STOCKTON, CA 9S20t388 <br /> 12091469-3420 <br /> E <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APR MAT ION N$11HDE EL MADE TO TILE SAN JOAW W CDVNIY FOR A ITRMII TO CON ITAUCTIANDMA INSTAIL THE WOW DESCRIBED.THIS AR'LICATION IB MADE IN COMRIANCF WITH IAN <br /> JOAQUIN COUNTY EVFLOPMENT TRIS,CIIAPIEfl 81116.3 AND THE STANDARD@ OF BAN JOAQUIN COUNTY RINIIC IIEALTII SERVICE.,ENNroNMENTAL IIEALTII GM.IUN. <br /> JON AIMREBRroR AMM ,���/S I� CITIO(y (Jn PARCEL@12EIAPNF <br /> OWNIR'E NAME <br /> COn lQl Y!! ""^�' App11E6@ ///111 RgNE I q3/C,/o/ <br /> MMCTON <br /> __UAI E�t",`r! 'F ADDRESS Q yypNF I� <br /> S10 CONTRACTOR ADDRESS TICS <br /> �y� MGM I <br /> TYPE OF WEI/JFVMP: DO NEW WEIL ❑ REPLACEMENT WTI I ❑ MONITORING W'EIL/ ❑ OTHER <br /> ��L �❑ ININSTAIUTION ❑ MIAL SYSTEM REPAID ❑ CROSS CONNECT REPAIR El VAPOR EXTRACTION WELLI J <br /> -�00YPEoL[ IEfNw❑Rro.lr IIP,1. 0 UEPIIIRIMP6Et FT. FIRST WATER LEVEL /�� T— <br /> rtYPE OT RIMR ��•�1 T p <br /> 11001 Or SERVICE WELL 11OEOIYIYSICAL WELL 1 ❑ SOIL MMO B <br /> IJ OE 61 NIICI IOIP <br /> INTENmrEn TYPE OF WELL CONEIRUCRON SPECIRCAIIONO <br /> ❑ PROUST MAI ❑Omn no ROM YF DIA,OF WELL EXCAVATIONL,(n 1 DIA.OF CONDUCTOR CASINO n <br /> OO <br /> 42 O <br /> � DOME911CBTIVATE qy AMVEL PACKISIIE_ IYR OF CASINO/SIEfIRVG_ DIA.OF WELL CASINO I, <br /> ❑ FLNIICrtAUNLCIPAL Ll DRIVEN DEPTH OF OMM SEAL BITC11IMATION nS <br /> ❑ IMKIMPON/AO ❑OTIIFR BMW SEAL INSTAIIED BY �/�L��//������ DIOUT BRAND NAME E <br /> ❑ MONITONIIO / GROUT SEAL MUMO: kfy- L1 NF CONCIIE,E PEDESTAL BY DRILLfII I�Yw ON. <br /> S s <br /> APMO%.DEAN _ LOCKING CHESTER BO%/BION!RPE <br /> S <br /> RIOIOSER11E <br /> O COMtTT10N/IN.IUNO."Me; MCA,IroTApV .( AIR ROTARY AIIOFq CABLE OTHER <br /> to CERTIFY THAT I HAVE PFn PARED THIN ARLCATION— �/AND THAT TIIE WOW WALL BE DONE IN ACCORDANCE WAIN SAN JOAQUIN COUNTY DIDINANCES,STATE LAWS,AND RULES AND <br /> P[UUTATION6 OF THE BAN JOAOUIN COUNTY. 110MF OWNER OR LMEN{ED AOFNT9L OMNATIME CfRTIF1E6 THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> 1111{RTAAII IN ISSUED.I$"Ali NOT EMPLOY RRSONG M ISACT TOWOR AN-6 COMPEN{ATFON LAWS OF CAMORNIA.' CONTRACTOR'B AIRING OR SUBCONIRACTINO SIGNATURE CERTIFIES <br /> TIIE FOLLOWING: •I CERTIFY TIIAT IN THE PERFORMANCE OF THE WORN FOR WIRL11 TIIIB PERLIN IS ISSUED,1 SIMM EMPLOY KnINGA ,SUBJECT TO WORKMAN'S COMMUNICATION IAWB OF <br /> CAUFORNIA'''�T�UC M CAN M 4 CC/A(�L�LN INPURS IN ADVANCE FOR ALL REOUIIW MSPWMNS AT 1"4114"4 22, COMPLETE O WINO AT LOWER AREA PNOVDEO. <br /> BIBrrJ% /_/��Y ��', IH yf7� D.C. 3-3- 97 <br /> �` nor RAN ID..«-e Basel San. •le <br /> 1. NAMES OF IIIEEIB OR ROADS NEAREST to OR BOUNDING TIIE FIIDRRIY. S. LOCATION OF IIOUBE BfWAGE GRIMM SYSTEM OA NgIb BFD <br /> 2 OIITUNF OF THE INro RRTY.OIVINIO DIMENSIONS AND NORTH DIRECTION. EXPANSION F BEWARE MAGE GRAI-SYSTEM{. <br /> 3 DIMENSIONED OUT-INF@ ANO LOCATION OF All E%IB TING ANO FITOMSEU <br /> BtRl1GIUTIEB.INCIUp1110 COVERED AREAE @DCII AS PATIOS,pRIVEWAYB,AND WAUB. S' LOCATION OF MIIB WTTUN RADIUS OF ONE HUNDTIEO FIFTY FT. <br /> ON THE PRORRTY OR ADJOINING PROPERTY, <br /> e F <br /> Al <br /> lEJ /-t/arh <br /> �rs>rF LJ <br /> °9 <br /> elf <br /> �,\ ® 'L 5 <br /> I15 - <br /> . - <br /> JAN,.. Lv.11illN t lJl'1!'J I , <br /> PUBLIC HEALTH SERVICE' <br /> DEPARTMENT WE ONLY <br /> AP.Ee.11w Aeawl.e By <br /> D.E.— <br /> Orpl1 MnP.aIIM BT ONE II ���''11L <br /> ` NyrIP Bxpw11M BY ON. <br /> Omn.:INn hPSRon Ry / <br /> D.1. <br /> celnn..x.:�ooc,J SPi.F�/ �r �•.A H�" I� /A1<<IR.GC.Cf� a �i� Olaf AOLp����� �( � Co <br /> IFACL'✓—v-'_CcF E.� wcG[� t <br /> ACCOUNTING ONLY: MDI FAEI <br /> IE COD" FEE Iwo M10UNi9,RFM111ED CIIEC /CAST/ RECEIVED p',A�/� PgWOIISO�E REOUFIT NUNISNI INVOICE ✓ <br /> 4 7 9 035$ <br /> 0:50 — 0 0358 go <br /> A <br /> Pub.Health Serv.-EOVIlO. 173(3/96) s�: <br />