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APPLlt;AIIUN-FUKWtLLdrUmrrttiMiI110CG7 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV/ ES/ G <br /> *VIRONMENTAL HEALTH DIVISION D <br /> 304 T WEBER AVENUE, ST:7CKTON, <br /> (209) 468-3420 <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplots In T1Ipikstsi " <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDAOPI INSTALL THE WORK DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WITH IAN <br /> JOAQUIN COUNTY DEVELOPMMEN�T TITLE.CHAPTER 9-1115.3 AND THE Ih ANOARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER.ENVIRONMENTAL HFALLR{OMmON, w <br /> JOB ADDRESSIOR Am,—L7(1 tc m'-9f ILL ^ • L CITY J99C��N+ � '" PARCEL BIZFlAPN71l � FE. <br /> OWNER'S NAME_' 5 TTTTI��--µ�� ' A ,Ess (1../ 11 PHO <br /> CONTRACTOR / R ' ADDRESS /V C UC! NEI f)7 ; <br /> I BwC at <br /> sue cGNrRAcroR� � Z —S%><u T r AvorasBMa_Y CAS 99-'6-3 Lics &!L6Y07 PHaNEIS/O-3/S-.SpOD <br /> TYPE OF WELVPUMP: 11NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER (:PF <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑N.Roo.lr HP. DEPTH PUMP SET---.FT. FIRST WATER LEVEL O <br /> HYPE OF PUMP/ <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELLI BOB-00RING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTAMTION SPECIFICATION/ y ff A <br /> ❑ INDUSTRIAL ❑OPENBOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO AJ 11Y O <br /> ❑ UOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELNYC AL/1A _ DIA.OF WELL CASINO {y1A / O <br /> ❑ pueLic MUNICIPAL ❑OmVEN DEPTH OF GROUT SEAL -7'07,2/1 eyep— "1/l SPECIFICATION Oto fPti��' lbF A,71TSLJ/I'� R <br /> ❑ IRRIGATIONIAO M OTHER GROUT SEAL INSTALLED BY CAA 1 L rQ.Q"TO/_ ORDUT BRAND NAME A/ /-7 E <br /> C1 MONITORING `` GROUT SEAL PLIMPEO: ®Y« 11 No CONCRETE PEDESTAL BY DRILLER-❑Y« 0 N A/IA5 <br /> O / J <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE I <br /> IgOPO6ED CON6TRUCTON/DPoLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHEfl TAY LC <br /> i HEREBY CERTIFY THAT I HAVE PREPARED THIS A CATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH AN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> ItEGUUTIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE MUD"-NO!-1 CERTIFY THAT IN THE PERFORMANCE OF THE WOHC FOR WNKH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA: CONTRACTOR'B HIRING OR 6UBCONFMCTINO 610NATURE CERTFTE6 <br /> THF FOLLOWING: *I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 14 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 13O4D <br /> 14404A31. COMPETE GNAWING AT LOWER AREA PTK IDE0. <br /> TIII. _l%h �A / M0'N r— 0.1. <br /> MOT PUN Lwµto Sala Satl. -to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR MgTV SED <br /> Z. OUTLINE OF THE PROPERTY,GING DIMENSIONS AND NORTH DIRECTION. EXPANSION Of SEWAGE d6PoBAl SYSTEMS.EMS. <br /> 1. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY M. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PfgKRTY OR AOJOININO PROPERTY. <br /> MRP0- c' <br /> P <br /> L_ <br /> DFDARTMEHT USE ONLY /�19 <br /> APPlle.nm Al" l Br Dote <br /> G.aVt 1rwP«Don BY Dol. Pune Wroonen ar D.t. <br /> 0«Iacllen Imn«tbn BY G.t. <br /> C.- ...t.: d <br /> F S OJ K7aAJ — /�10 <br /> ACCOUNTING ONLY: ND/ FACT C05 I//{rY/1 D <br /> PE CODES FEE INFO AMOUNT PFM1BTTED CHEMUMASH RECENED SY DATEP9NRTISFAVICE REGVFST NLBNBFR INVOICE <br /> O ' SEs I V0 C*7-1 (zr h6 <br /> Pub.Health Sew.-Enviro.173(1197) <br />