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• APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES • <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX SHO,304 EAST WEBER AVENUE,STOCKmN,CA 95201388 <br /> (2991469-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED <br /> ICeNRIAR IN TIIFRn1El <br /> AM-ICAT10N IR MFE EV MADE TO THE IAN JOAOVIx COUNTY FOM A IFW.IR TO CONRfRUCT AMM1R INSTALL THE WOR[OM.SM.TMB AMMATRIN 1f MADE IN COMRIANCE WITH EAN <br /> JOAQUIN COUNTY Of GFA,WTRLF,CHAPRR 9.1115.3 MEET 711E ITANDANDE OF RAN A OUN COUNTY INMUCCHEALTH IERNCFE.ENVI1pHMfNTM HfMTH OMtpN. <br /> JOe AOOREMAGA.1 Is 4 1 Q D <br /> I-2,46- cm C O / ITHOM DRjMM/ <br /> OWe <br /> IrtR' NAME /(�3rmA AG I'21_ AGoMM /) )� -ueAjee /CEFL-V Hp�I. Ki8-`/y52 <br /> CONTRACTOR- /PC 1 f/a HJ Sq fW b T/r AGORAE. LCA/ / C/f 9.5 Z PoONe/ <br /> ADdFa9 Ix/ PHauE r <br /> TYPE OF NfWNMP ❑NFWWFLL ❑R,,ACFMEM YIFLL ❑MONIONNGN t, V OTNFR_(¢E})a/`� (� <br /> 0 MRTAHATH N 0 ARM Gy"ll"FAIR [ICGGAE CONNECT REPAIR 0 VALOR F`%T FACT—ROSH WELL/ J <br /> 0 Nw 01Ne.N NP. OfRH RNR GET FT. LMI. D <br /> RVIF OF FUNK AFI <br /> FRIT WATER <br /> 0 OVi-0FGENTI CF WtIL 0 OE*FNM.M WELL/ GT FOIL wo. R <br /> ❑DfefNICTpN: <br /> INTENDED USE TYPE OF W CONFIRUCl10N AEN.AIIONF A <br /> 01NGUSTREAL 0 MN"TOM ON.OF WELL ERCAVATgN dA OF D.MGUCOR CAGING p <br /> 0 OOMEGTI lM VATF C OMKL PACx/GUM T Of CAMNdFTE U d4 01 WF11 CADNO p <br /> ❑RMUCMUNKWAL 00RVFN DEPTH OF GROUT WF DIXOf INTU. R <br /> ❑RMOATIONIAO ❑OTHER ,MUT FENT MGT..Gr GROUT GRAN)NAME E <br /> MOMfO.. �/� / GROUT RM NMRP. 0V-—0. CONCRETE ROfAAL SV MTL[n:O V. 0. ,G <br /> AHEAD .GRT. J y LOINUM CMREM WXGGOVE PR[ ] <br /> FNOFOEm CONSl11VC1N)N/dRI1NG METNpO! MW ROTAM Ad ROTARY.AUGER CAe1E OTHER <br /> I"MAY CERTIFY THAT 1 NAVE NIEFARED TMG AITUC —AND THAT THE NORI W RE GONE M ACCORDANCE WITH GAN AAO NI C.V GOINANCFG,STATE UWF.AM RJUS AND <br /> Rfl, .DNR OF THF GAx JOAQUIN COUNTY. HOME OWRRR OR MO,,HR G M,.GpNATUM CERfNR9 THE MUOVMO:'1 CERRI THAT M THE PERFORMANCE OF TIM NgNL EGRTM R N <br /> THIS PRWN19 R91RD. RHML NOTFM0.0V FFRSONR GUehCTTO WOAWAM'A COMFpAA00N UW'G OFCMIFOIMA.'COMMCTOM'EMRN.OR.U"oO MCTMOGIONATIIRCtRf e9 <br /> THE MUOWrNO: '1 CEIRGY THAT IH THE FERFORAANCE OF THE NON!MR WHICH THIS MEANT IR 11.0.1 MAU fMMOV FERMN.SUW,D,TO fMMMAN•A D....ATRN UNA OF <br /> CALDORMA.' T AERMANT MINT CALL].HOURS IN AWANCE FM AM AEgMED INAI EETOP <br /> NG AT MItl.L <br /> //. F2�..EECOMRME GAMIN,AT LOWER AREA PION EO. <br /> G �K� III. 1/_ 6RcAs Is7� ,5;Nex/il- <br /> ROT MM DI,-v,t w W414Y._ <br /> 1, NAMEGO OF THEFTFORROADA NFAIIEST TOMNIT ON ANDA HD,TN[NORgTy, A, �ATKDN F 1OUFEGfWAOE d9PoSAL9YSf[M ON PIOPoGfD <br /> ]. OUTLINEM THFROFEIRIf.N UMAATAND ION.1O ANOINGA dRtiON. F LOCATION Of AfWAOFTHIN NE RVOEON <br /> ]. E EN9ONE0 OMI111iF AND LOCATOR OE HL A.FATE.,O IIIOPoGFO E. LOCATOR OF WEW WNFIIH MGVG OF ONE MlNdlfO i1RY FT, <br /> eTRICTVRG.INCLVpRp(CIOVER,ARAB BUC•H,TM PAiOS.MVFWAYS.AHp/W�AIkS, ON THE ROFERNOR ADMAN.NOFFMY. <br /> /UQrN��47/ <br /> w� <br /> A.Hw.Iwn A....Ir er_ m rr oa. <br /> R.HA I�y.mllm er <br /> H. NImA In..aRen er OH. <br /> OrHwlbn Ir.Yp`aEL'�len er O.0 <br /> mms .:elf JG /'L F�J5. 71•y TO) Otis(-0337 /d 6f 46 hs»rs ,n gdii, m <br /> ACC. .G.�OQ..LYI:L�,A�✓P �nJ�I AID/ FAC/ <br /> rt CODES EUDEM AMOUNT MWITm CHECx/ICAR. RECpVEO GY DATE PTERATMOMCE RIOUFET HUMMER ....Cc <br /> vl Z X4W ;73.. —co 4 <br />