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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 386,445 N-SAN JOAOUIN$7,STOCHTON,CA 95201-388 <br /> 12091468-3420 <br /> KOM-REFUNDABLE PERMIT E%PIPES 1 YEAR FROM OATS 1SSUEU <br /> iu-pktf OI TTIpOEfte1 <br /> ATWJCATWN ISHEFE BY MALIE TO THE SAN IOAQUIN COUNTY FORA PERMIT TO cOJISTRUCT AIFOIOR IkBTAIi THE WOWL DESCRIBED.TIRE AfPIICATIPH IN[.FADE IN COMPLIANCE WITH SAN <br /> JOAOUw CWNTY OEUELOPMVFf�T IT TLE.CHAPTER 9.1115.3 AND 1HE"MOAMS OF SAN JOAOUIN COUNTY FIIBLICEH�EALTH BERWEx,ENYIRONMENTK HEALTH ENVISION. <br /> JOB ADDAEBBNR AnJF IIV W• �L�it CITY wI)J: PARCELi WAFNF <br /> 1 dab�naA s sre r�� <br /> - PPrtlNTE NAME �n.+yklC1J/V 1 C"A�CrJ ia' ADOFlef�n, <br /> CONTMCTOR„� 7.�wvi �/ __ AOORESf�O ♦T.IISs+.�!/Lr<d4Gc+ WIONEI <br /> BLIB coif A .R M _- –�AnPREBFf"-C• �►; 177k R t.T„«.uc. FNONE+ <br /> TWEOPWEu,au P: ❑f NEW WELL LA RFmM1 gig ENT W u ❑MOMTOWHG WELL0 ❑OTHER <br /> 4„I INSTALLATWN ❑WELL SYSTEM REPAw ❑clq—oNmFcT REPAW ❑VAPoR EXTRACTION YVELL F J <br /> ❑N—0 RFFMr M.P. DEPTH PINJP SET__FY. FNSST WATER LEVEL O <br /> [TYPE OF PIIMPI <br /> IEl ❑0 <br /> ))r-0ERME mu �.E ❑ao�Hracuyw.iu/y•T ❑ SOL orvG n/ a <br /> DBWgN: 1/W+s-"ci s",X/' <br /> r(11�4Lc- FSA <br /> !N AIOEP YE I�-IFE OF EONJITRUCTION—IFICA ION 7 I <br /> ❑WOUBTRIAL ❑OPER BPTTPM DIA.OF WELL EXCAVATgN OIA.OF COWUCTORCASINO D <br /> ❑OOMESTN:N vmi F❑ORAVEL PACXT8ITE TYFE OF GASIMMTEEI C VIA_OF WELL CASINO D <br /> ❑PIISLICREUww: LJ(-Yy MVEN DEPTH OF GROUT SEAL fPECwi:ATION R <br /> 0l ATIOWAG ❑OTHER /TROUT BEAL wSTMLEO BY —uT—NAME E <br /> 0 MPMTOJENu GROUT SEN MMFEO:❑Y ON. CONCRE fKMSTALBYDWIIFMOY- ON. $ <br /> AFWEOX.OEFTN IDCAWP CHLSFLR SOXIBTOVE S <br /> FFIOwBEO CONSTRIlCT10NIDWLLMO Mi1H00:MUO PoTAf{Y IJP ROTARYAUGER CARIE OTHER <br /> I HEREBY FO <br /> CERTIFY THAT 1 NAVE FIFEPNAFO THIS APFUCATnN ANP THAT THE W W MMLL BE VOHE W ACCORDANCE MATN SAN IGAWIN COUNT•!OFOMANCES,STATE LAWS,ANO RULES ANO <br /> WflULATgNB OF THE SAJF JOAPMN ll-"-NOME—IIA OR UEN <br /> CSEO AGENT'S SIGNATURE CERTNYA <br /> IEG THE FOIAOHO:'1 CEWIFYTHAT W THE FEFFOWAANCE OF THE WONT MR"ICH <br /> T UIS RAST IB ISFUEO.I SHNA IqT EMgDY PFfuNINN MlIUOc'f TO WONNAFAM'B CONPExeATION lwwB OF CNJFOPNIA.'COMNMTOR'B IIMw0 00.8USCOMNACTWO Bq NATURE CEIITIFIFS <br /> THF FOLLOWINU: I CERTDY THAT w THE PERFORMANCE OF 1HE MgNI FOR MRCCH TNF pEIUA,T LB IBSUFP.!EHAIL EMHPY FEJLSOIJB BuaJECi iO WORFUAAx•e cPMpluleamx uvMe PF <br /> CAUFOWHA.'QME APFUCMT Mu HOURS HOURS Ix APVMPE FOR ALL REOBS""Ix c xE PY,�TIWI X138.COMPLETE OHA—NO AT WWEA AREA PMVIPEO / <br /> A Gi/�Crh1 b111.1/11�v�/ TIP. r�-i.0 l,WCOM, D.I. — <br /> MM FLAN IO.Aw IF SO WI OwH <br /> 1.NMIES GF STREETS OR RO.GS W DIeT TO H BOHNDIO TETE CTION. A.EDCAT I N OF SfW ■EMSKI G18PoSTE SYSTEM OR FAOPoeCG <br /> 3.OI/t HNE OF THE FNOPERTY.OMNO DIMEN&ONS AND/IOFOH OIPECTgN. E%PMBgN OF SEWAGE pBPo&LL SYSTEMS. <br /> 3.pMtFNOONED OURINEf M0 LOGATgN Of ALL EX—AND PIgFO BED S.LOCATION OF WELLS WITHLN RADIUS OF ONE HUNOWO FIFTY FT. <br /> 3 <br /> GTR AER.O LUDwfl COVEMD AREA, <br /> SUCH AS PgATPS,OWYEWAYJ.AND W—S. ON THE FFNIKATY OR AE—ING I KRF Y. <br /> Lb �T -�+•,1�tJ r�cN�� <br /> r loft- 7S—srR-IJL_T40/J OF OPJP— �FFSF <br /> W&tt LocATE-.R /lr (AMWz-R3-r TO ATt'r <br /> TRON,ea-vi. <br /> c�f�SrT -LitbtL 6Al 1716-just zll I{1.7 s- <br /> PFPARTMENT PSE ONLY <br /> Appl6.Uan I�yld SY��7 OAn l I /.J Mr �•�I <br /> Prey V.n—BY n ttt OAT. PvmP IrwpE¢Uon 8y <br /> PE GROES F[F INFO AMOUNT RFTIRTES HEC ASH NECDVm■Y ..Tf TIBDTMCE l,FPUFAT NPNHIEL INVOICE <br />