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APPI.WAIION ON WELIIPUMP PERMIT <br /> SAN AOA(IUIN COUNTY PUBLIC IIEALTII SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ABOX M.904 EAST WEBER AVENUE,STOCKM, 95201588 <br /> 1209)4603420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED ' <br /> T ICBmPkI.ID TIIy1kS1.1 <br /> APPLICATION IS ITEM BY MME TO TIIE SAN JOAQUIN COUNTY FOR A FEWIT TO CONSTRICT ANDIOR UI6TALL TIIE WON:DESCRIBED.Till@ AMICATION IB MADE IN COMPLIANCE WITH BAN <br /> JOAOUIN COUNEY DEVELOPMENT TRUE.CRAI 11 BANDY STANDARDS Of 6M JOAQUIN COUNTY PUBLIC IIfALTHSERVICES,[NVIWNMfMM RENT11 DIVISION. <br /> JOB MONBBNfl AYNI n��"� � L� CITTYnY •_„ PAIICFL,BIFEE/APH1 <br /> /.dE oc, vDxn'!T'>'Ri M-11.SNn•� 'S. LSM/ l"A"+ �4 rE.N(Sf 2Ay--v <br /> O'M![nY NAME z �,��/� (J /� <br /> CONTRACTOR �zHB[.2C. Y�JFI nn✓!<bN.E /[iO'Q(PT/AUo11FpB UCEC'�" �[_NNU [ //. •/.1 <br /> -sIIBRro <br /> I <br /> nrt Of W tUpLIMI: ❑NFW WELL ❑Al".MENF IYELL ❑M.w....WALL/ ❑OTHER- <br /> 0 INSTALLATION <br /> THER❑INSTNUTION ❑WELL IIMIM NPN- ❑CIbBBCONN{CT REPAIR ❑VAPofl[%TRACTIOH WELLI / <br /> ❑N_ NPA R., Emil NMP SET____FT. r FOOT WATER LEVEL 0 <br /> -YPf OF MMPI ❑ p011iONNO B <br /> �,,(/ ,o�/J �J ❑OYT/-0/FBF-VICE WELL ❑OFONYBICAI'a'.(YOIBTRUCTLGH:1' /"LY/4AC (J DUT(/�[<- /L//✓-iz rY-M!c//? ,['c�Ela..��rC/y/t Z. /L'r'rrAF ,Ol. SrcC� <br /> Mama YLE TYPE OF WELL COILLTRVCI ON SPECIFICATION. A <br /> ❑INDUSTRIAL ❑ORN BOTTOM DIA.O1WE1L EXCAVATION ON,OF CONDUCTOR CASINO O <br /> ❑OOMINfflC NVATE ❑OMVEL PACRISRE nl'E OF CABIN6BT1D1PJC DIA.Of WALL CASINO D <br /> ❑NNCrMUNICIPAL ❑DNVM OE"ll Of OWN,6f AL 6P[CIFICATION A <br /> ❑INVOATIONIM 0O111ER GROUT REAL INSTALLED iY GREW 0.0 NAME f <br /> ❑MONNONNO OOR IStALRIMRO:OYw ON. CONC-ET{RDERTNBYDNLLENOVr ON. f <br /> APMON.DFRII LOCKING CIILRI[R--%I-T-W RPE A <br /> IROIOFID CONSTRUCTION/Ml1INO M"HOM. MUD NOTARY.AIR AOTAWV AUGER CARLf OTIIER <br /> I IIEMBY CERTIFY THAT I HAVE MEPAND MIB APMCATN)N MD THAT TIIE;ZIK WILL R ODNE IN MCOIIONItf W151 BM JOAWq COVNn ORDINANCES.STATE LAWS.NIO"REB NR <br /> REGULATIONS OF THE SM JOAM114 COUNTY.IIOME ONMER ODDCE W FO AGENT'S SIGNATURE C[NIFI{R TIIE FOLLOWING:'t CUTTRYTHAT IN TIIE rtNORMMCE Of TIIE YMIK MRM'Cll <br /> TIIM PNMT IB 16NE0.1 SIMM.NOT EMPLOY PERSONS RURJ[CT TO W ORAMM'S COMRXSATION"WOOF CNIFOIVA&'COMMCTOR'B IIINNO OR SU"GMMCTING SIONATUN C{NI'ltO <br /> lll{fOLLOWGNO: 'I CENII TIIAT IN TIIE IFNO NC[Of 111E WORE fOR WIIICII lI1V PFfMR IB IBSU[D.I BIIML[MA.OV RRSONB SUBJ[CT TO WOAWAXY COMPM.A90N LAWS Of <br /> CADFONIIA' TIIE A�M��All FE Y 111 AlIVA1rL'f IU11 AIL N.�,MI1YY INAIM)IO�I.MJ 1f.COM�ItFETf OMWIIIO AT LOWLfl ANA P1'RVU,F <br /> RO}PIAN IDrn IS bJ. RaJ.�'le <br /> A ' <br /> L NAMED OF pTN OR WADS NEANBT TOORBOVIIOINO TIIE RIOrtRn. ..LOCATION Of 110Ui[SfWAOF q.PoOTE IWIFTIM OR RpMSEOVOT . <br /> 3.OIRIINF OF 111E PW NRn.01NN0 OIM[NBIONS ANO NONII DIRECTION. [%PMBION Of SfWAOf gpPoSN S <br /> I OF ON. <br /> .. <br /> ).OIMENRION[0 OVT WIL.MO LOCATION Of ALL fX1611NO AND RW PoRFD B.LOCATION Of WELLS W1T111N RADIUOf ONE INNDRED FIFTY R." <br /> 6TRUClUN0.1NCEUDINO COVING ARAB 6UCI1 AB PMNB,DRIVEWAYS,AND WAIX S. ON INE N10PFRTV Ofl ADl01NIN0 RpRRn. <br /> MrJ r2 <br /> i... . .. <br /> ': ':. <br /> Sp L11L1� <br /> MAl i <br /> �nEnolr-(a R(!fu I i <br /> O[IMTMLNT USE ONLY <br /> AppW.Uon A[.pr Y <br /> N.N Mr.Ol.n By <br /> o.l. J•3'�L6 RNrr 1:.'vwuerr ur <br /> UrYu[Il,n ImprUsn By D• <br /> .....:,.; ' d Stork 5�U^�-�t1� (rrvtl� � ro38 iln,•kcl ACCOUNTING ONLY: <br /> ONLY: ALO/ MC/ <br /> It COE$ i[EINFO MOUNT IIWHTED OORECYJMAm1 MOVED pY DAA IERMITHO C[REQUEST NUMBER INVOICE <br />