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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> J ENVIRONMENTAL HEALTH DIVISION <br /> 344 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED <br /> IC@mp11T@ No TIllRINePI — <br /> APPLICATION 18 HERE BY MADE TO THE SAH JOAQUIN COUNTY FOR A PERMIT TD CONSTRUCT ANDR]R INSTALL THE WOW DESCIORFD.THIS APPLICATION 18 MADE IN LOMTLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1 116,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH CA"MON. <br /> JOS ADOWSS/OR APN► CLTY PARCtI S12E/Ar'N0 <br /> r J J _ f <br /> OWNER'S NAME—��., L'i f./ 7 % AD... 1..� '�/�I_f? %C'f`C vL t'Y_ - I410NE R_� <br /> CONTRACTOR /i�- .�- i'i' ADOrt88,fi v'/�'�; J -_ - LICA_ J-3 PHONE F <br /> SUN CONTRACTOR AOORM88 -�- LICr�--- ATONE s <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER_ <br /> ❑ INBTALLATICN ❑ WELL SYSTEPA REPASR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL IF J <br /> ] N.❑Rep k H.P-__ DEPTH PUMP SET�FT, FIRST WATER LEVEL 'L •�—J O <br /> fFYPE OF PUMPI <br /> Cl OITT-0E-SERVICE WFTL ❑ DEOAIYSICAL WELT.I ❑ 19010 BORING g <br /> ❑bEIFI#/If7EFT���ILC t.�' r JL t � � !r r A- - �.f( ( 7. .ijl <br /> INTENDED USE��� TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> © INDUSTRIAL ❑OPEN BOTTOM DNA.OF WELL EXCAVATION ORA,OF CONDUCTOR CASINO D <br /> , DOMtBTIClpPpVATE ❑DRAVEL PACK/BIZE_ TYPE OF CASINO/STEEUPVC DIA_OF WELL CASINO J r/ p <br /> ❑ PURUC/MUNNCIPAL ❑O14VEN DEPTH Of GROUT PEAL _ SPECIFICATION p <br /> ❑ SO80ATION/AG ❑OtHER GROVT SEAL IHBT A LED BY � GROUT BRAND NAME 1: <br /> ❑ MONITORING -y GROUT SEAL PUMPED: ❑Y. ❑Ne CONCRETE PEDESTAL NY DRILLER;❑Ytw ❑Ne 5 <br /> APPROX.PEPT141 �f LOCKING CHESTER BOWNTOVE PePE S <br /> PROPOSED CONSTRUCTION/DFILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> i HEREBY CERTWV THAT 1 IIAVE PREFARED THIN APPLICATION AND THAT IME WOR(WILL BE DONE IN ACCOODAWIF WLTH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RALES AND <br /> REGULATIONS OF THE MAN JOAGI M COUNTY, HOME OWNER OR LICENSED AGERrF'■SIGNATURE CERTIFIES THF FOLLOWING:'I CERTIFY THAT IN TILE PERFORMANCE OF THE WORK FOR WINCH <br /> THIS PERMIT 48 ISNUED,I SHALL NOT EMPLOY PERSONS SUNJECT TO W010MRAN'6 COMPEFI@AT1ON LAWS OF C/,LIFOIMNA-- CONTRACTOR-S HIRING OR SU"ONTRACTBIG SIGNATURE CERTIREN <br /> THE FOLLOWINO: 'I CERTIFY THAT IN THE PEFEOPMA.HCE OF THE WORK FAR WHICH THVB P£INJ11T Y6 188VEU,i SHAM tU8'LOY PERSONS NllBJEC7 TO WOIRIOMAN7 COMPENSATFON LAWS OF <br /> CALWORNIA�.�• THEE APPUCANT MUST t 24 HOURS IN ADVANCE FOR ALL REt2UNIED INIPM�TONs AT iY0E1 PSN-34". COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Skn.e X Lt'`-[�r'�' -!1f'7� --� TRH._ - f. /�.• Op. ..L.,r �.. <br /> FLOP PLAN(De.w to Se.I.I Soal. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PRDFK)Kb <br /> 2. OUTLINE OF THE PROPERTY,ONII10 OMEHMNS AND NORTH T)IRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM@. <br /> 3, DOAFMOONED OVTLINFE AND LOCATION OF ALL EXRTTMO AND PROPOSED S. LOCATION OF WELLS WrrW V RADIUS OF ONE HUNOWD FIFTY FT. <br /> STRUCTURES,!INCLUDING COVERED AREAS SUCH AS PATIO@,DRIVEWAY@,AND WALKS, ON THE PROPERTY OR ADJOIMNO PROPERTY. <br /> t\? 1 <br /> i <br /> f,' f EP TM T USE ONLY <br /> Appllenlon A.ow ed BY_ V O.l._ % f f I A,,w ,+1 <br /> Ore."Iapmelon BF_ Oat. p--v Ir»gecU - f2h 1 "T— <br /> Dn.tnrcllen"r—Ow,Nv _ ,^ Date f, <br /> C.--w*v <br /> ACCOISNTINO ONLY: AIOI FACS <br /> h COpE@ FEE INFO AMOUNT FWATTED HEC /CATH RE[pVEO NY DAT INVOICE <br /> Put) Health SBev.-EnvirG, 173(1/97) <br />