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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PU81- TALTH SERVICES <br /> ENVIRONMENTAL <br /> H�A"A�Tbox 988r"F ,,%X 1EASTWESER AVENUE, CA 95201389 <br /> 0 <br /> l� (209)468.342 <br /> 915 SCP _ft AM 10:20 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICampkis In TTIPIkBttl <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUHTy FOR A PirnmiI TO CONSTRUCT AMDMII INSTALL TRE WOW DESCRIBED.Title APPLICATION IS MADE IN COMPLIANCEWlIII SAN <br /> JOAOUPN COUNTY OEVELOPM77EM TITLE,CLIAPTER 0-1 t 15.3 AND 111E STANDARDS OF BAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMTNTAL HEALTH DIVISION. <br /> JOB AODPIS91011 APIr1 4 <br /> RCFL SDE/AITJI 1 j Z.�'C, <br /> /1 _nrr PA <br /> �� (�] � <br /> OWNEM1'S NAME unLUP9 I[1� T'n AODRE.BB -TOO <br /> PHONE <br /> / <br /> CONTRACTOR P.S <br /> —�Sst_L�1 S IL AbbT1ERe I I2`�T a1 'f C[i5 t�C"S fe E1CI�IJ�Sl 7L34+4K Q <br /> AVB CONIRAC7OR rf T�� <br /> C' ADDnEBB 3..� 1 Ei,41cI !O(�L�Q RLIDNE T 1 S��-3L'+( <br /> EYPE OF WELL"MP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONO CRINO WELL F ry} <br /> ❑INSTALLATION CROS$ <br /> TION ❑WELL SYSTEM REPAIRIIS OTHER_ 1 I 1]cIQ.t' S✓'V V J <br /> CONNECT REPAIR ❑VAPOR EXTRACTION WELL/ ! <br /> ❑Nwv❑n^..E+ N.P. <br /> H YPE OF PVMPI aEPIII NMP SF,T,-_FT, FR187 WATER LEVEL <br /> 1`�T ❑OUT-DT'SEnVICE WELL ❑OEOPt1YSICAL WELL A ❑ SOIL ROBING <br /> LT OEBTRUCTTON: Rs y11 f/�U R <br /> INTENDED USE TYPE OF WELL CONSIRUCIION SPECIFICAlIONi <br /> ❑IHDuGIRIAL ❑OFFN BOTTOM A <br /> DIA.OF WELL EXCAVATION �. Z_�,/ DNA,OF CONDUCTOR CASINO <br /> ❑POM EBT ICA9"VATE ❑GRAVEL PACK/RDE iI <br /> NPF OF CAxIHGIST[FIfiVC DIA,OF WTLL CASING <br /> ❑PVNI <br /> RLICIMUCIPAL ❑DRIVE.N —I I, <br /> nEPTtI OF GROAT SEAL '— <br /> ❑[BRIG ATIDWA0 ROTTIER <br /> CROUP 6FAL fNSTA[I FO By SPECIFICATION R <br /> Eye M'M' <br /> TONSnow 8RAND NAMEHO FF--�T []1 E <br /> AP1El0%-bF►TH <br /> GROUT BEAT PUMPFO:I.J YIy yy Ns f.ONCnETE TEOTBTAL AY ONILTR❑yr INa 5 <br /> S/ LOCKING CNESTFR SO%IR10 VE+TfE <br /> PROPOIEO CORITRUCTFONIDRILUNO METHOD; MUD ROTARY AIR nOfARY AUOER <br /> CABLE OTHER <br /> I HE9ERy CERTIFY THAT I HAVE PTICIARED THIS APPLICATION AND TI/AT THE WORK WILL HE GONE 1N AGEGIVTANCE WITH BAN JOAQUIN COUNTY OMINANCE8.STATE LAWS,AND RULES AND <br /> AEOUI ATION9 OF THE BAN JOAOVIN COUNty.HOME OWNER OR LICENSED AOENT'S SIONATURE CE RT HIES THE FOLLOWIHO:•I CERTIFY THAT IN TILE PERTOnMANCE OF THE WVW FOR M1101 <br /> TIII"PERMIT IB IRBUED,1 SMALL NOT EMPLOY PERSONS SUBJECT TO WONXMAI-I COMPENSATION LAWS OF CALIFORNIA.'CONTRAC70A'e HIRING OR BUB-CONTRACTING SIGNATURE CERtITEE6 <br /> THE TOLLOWINO: •1 CERTIFY THAT IN TIIE PERFDRAIANCE OF THE WORK FOR YNIfCH THIS p,,nMFT IB ISSUED,1 SHALL- COY PERSON"SVRJECT R S COH FIACN'll INq SIG FAT RE LAWS OF <br /> CALIF011NIA,'[/T�)I�E AViEICANT {T GAIL 24 HgIBR{IN ADVANCE FDR ALL R[GUREO IN i PECII NE AT I;pS7 II,COMTLEIE DRAWING A_T LOWER AREA PROVIDED. <br /> 'T— D,n ( <br /> IPLOT PLAN 1D—to 8.w1 W.I. <br /> .NAMES OF STREETS OR ROAOB NEAREST TO.01110 VHDINO THE PnovEnTy, <br /> 3-DUfUHE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. �. LOCATION OF HOUSE SEWAGE bl"PORAL SYS7FM GR 1`MmaEO <br /> 7,OIMENSIOHED OUTLINE,{AND LOCATION OF ALL EXISTING AND PRDPoSEO EXPANSION OF*MADE DIBAO{AL SYSTEMS, <br /> {IRIICTVRE",fNCLVPINO COVERED AREAS SUCH AS PATIOS,DRILTVEWAYS,AND WAB, {.LOCATION OF WELL"WfTMN RADIU{OF ONE PIUNb11[D FIFTY FT <br /> ON THE PROPERTY OR ADJOINPNO pRDPERTy. <br /> Ice Piani <br /> 7t <br /> o <br /> c <br /> s <br /> i-cr,A�� <br /> O <br /> ILL <br /> iJrdey �oi rit' <br /> .A. O 1 <br /> S11Drav�¢ <br /> a L31dc� K n v J� K <br /> FILECOP <br /> LLVYdsu1 StI.: <br /> DEPARTMENT WE ONLY <br /> ApPll.,ei—Ava 'P Br O.I•�'. V 9 <br /> O,uul I,..P,clbn BF bH• P—P 1-'—dan BT <br /> bee• <br /> De,umPl.�Irnn«uo.I BF <br /> D,I <br /> ACCOUNTING ONLY; AfDP <br /> FAC/ <br /> FE CODEI FEE turc AMOUNT REMITTED CHECK&MAIH [ RECEIVED IT bAFE Pt11P.071{EIVICE REGVF9T NUMBER INVOICE <br /> 5O1 2 45• 010320 <br /> Pub.Health Serv.-Enviro.173(3195) <br />