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0 <br />Li cit 7 3 -7 7 <br />IZiovi <br />5,z4.4724,....-, <br />FT. <br />NEW WELL <br />OESTRUCTICN <br />Ti INSTALLATION <br />Nae 0 Repair <br />T'rPE 1F WILL/P1JMP 7 <br />OMER <br />Tam WRING A( <br />VAPOR EXTRACTION WELLS_____ <br />FIRST WATER UEVEL5-0-4<-' / <br />REPLACEMENT WELL marcarm ALL * 3 <br />OUT-OF-SEAVILE WELL 0 GEOWSICAL WELL IR <br />I0ELL SYSTEM REPAIR 3 GMOSS-COMMECT REPAIR <br />R.P. OUTS PUMP SET <br />lEa DATE PE <br />110114EFWIDAIRLE MINT MMUS I YEAR FRIEIM DATEISSUEU <br />here by node to the San Joaquin County for a permit to construct and/or instalt the wort described. This application is <br />ance with an Joaquin County Oevelopment Title, Chapter 9-1115_3 and the Standards of San Joaquin County Public Reslth <br />ronmental Masan Division. <br />L.:!;,1<i,"(CC APS* <br />City <br />(TYPE Of PLAN') <br />TYPE (Platt <br />INDUSTRIAL 0 OPEN SOTTCM <br />DOMESTIC/PRIVATE EI GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL n ORIVEM <br />UVRICATION/AG 0 OTMER <br />NONITCRING <br />AMU- DEPTH <br />omposen CZNSTRUCTICKIDRILLIMI WHOM <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION 57 " <br />rYps. OF CASIMGISTEEL qC <br />DEPTH Of aROUT SEAL <br />2ROUT TEAL INSTALLED 3Y <br />mut SEAL PUMPED: Il Yes 0 <br />LOCKING CXESTER SOX/STOVE PIPE <br />01A. OF CMODUCTOO CASING <br />DIA. OF WELL CASING <br />SPECIFICATICU <br />GROUT &RAND AAME <br />CONCRETE PEDESTAL SY DRILLER: 0 <br />MUD ROTARY AIR ROTARY AUGER* CABLE OTHER <br />I hereby certify that I have prepared this applEcation and that the 400( will be done in <br />accordance with San Josquin County Ordinances, <br />State Lams, <br />and Rules and Regulations of the Ian josquin County. Hone owner or licensed agent's signature <br />certifies the following: *I <br />certify that in the performance of the wort forrnich :his permit Is issued. I shell net employ persono subject co.UORKMAN'S COMPENSATION <br />Laws of California." <br />Contractor's hiring or auq-contracting signmture certifies the following: 4 I certify that En :he performence <br />of tna .Jork for <br />uhich this permit is issued, I saall employ persons subject to WORKMAN'S =NRENSATION J-awc of <br /> THEAPPUCANT <br />ZUST CALI 24 HUSS UR ADM* FIDIkALL REWIRED INSPECTIONS AT 011444.2423. <br />Complete irewing at lower area provided. <br />Signed X \ <br />Titte <br />7). Da te 5"241/q" <br />I. <br />I <br />(2 <br />oj <br />Ares cpruAl0 el 01-,4:e Date (,-, -7 -4 <br />NM, Casements: f'Z i-Jr(t"lfrCi, 7/, — Jc,-ti si}si <br /> <br />oats i?/"1797 Pismo In Oatespection dy <br />FACO <br />-4)6 51,4.4.1t 4,A.X.k. e...If G4,4C4-,..S" <br />Application Accepted Ty <br />GraUt Inspection We <br />Destruction Inspection 3y <br />ACCOUNTING altLY: AID* <br />DEPARTMENT ISE any <br />PE =on FIE INFO <br />753-0 ) `-1 <br />AMOUNT REMITTED CITECIIJICASH <br />1 iyoG <br />RECIIVED SY <br />-5A2C/ -1' 3 -7:2/ \I <br />)1 <br />Yes %No <br />A-PPLIOATIal FOR WELLIPUMP PtRMIT alb <br />JaAaUIN CoUNTT PUBLIC HEALTH SERvt <br />ENVIRONMENTAL HEALTH OIVISION <br />P 0 30X 3111. 443 L SAN JoAcLUIN ST. sTOCITOL C 0.01-312 <br />aoS) 488-0420 <br />Application is <br />node in compli <br />Services, Envi <br />Job Address/or <br />Parcel Sfze/APsd <br />v-t.t.5.3-764. <br />\ ?.1 Address ti <br />C <br />/ ontractor <br />Sub Contractor L.L4'1 Ok.,4 I 1..ik 7-• K6-‘4.1....ddrris i <br />Owner's Maine <br />Phone 0 4/ 6 2 " 7 `tCC <br />Phone <br />Phone * 772 <br />Address