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vng2 ,L <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 488-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> MemplEtl M TrIpRRR11I T __ <br /> APPLICATION IA HERE BY MADE TO THE SRN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DEICRIBED.TING APPLICATION m MADE IN COMPLMNCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TRtE.CHAPTER 5-1115.3 AND THE STANDARDS Of BAN JOAOUIN COUNrY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTEi OMMM. <br /> JOS ADORESSAR AP'N+ kc—O' e,Ty <br /> J VVJ�I�,yrJ✓� ���/PAyR.CEI.1lR,E�/AyPN�+ <br /> OWNER'/NAME AOOIABS 2 0. f)3b?k 9 �y��./��If Uf�•!L W PHOONEE tt9S�JVj.7"] <br /> CONTRACTOAPOY� NGS-!i/ AODRESf. ! �, L.� 1J{Ge LICE PHONE R q4d;2 5()c�o <br /> SUB CONTRACTOR l t/ ADDRESS �/.1 LICe� PHONE I <br /> TYPE IF W&LftMm(3 HEW WL'LL ❑ REPLACEMENT WELL ❑ MONITORING WELL R iC3.OTHER N SSJPL�,r <br /> +G.INSTAL xam ❑WELL SYSTEM REPAIR ❑ C110OWCONNECT REPAIR ❑ VAPOR EXTRACTION MU I J , <br /> ❑Naw❑Rsp.► H.P, DEPTH PUMP SET FT. FIRST MATER LEVEL Q <br /> IT YPE OF PUMP 1-'1 <br /> ❑ OUT-OFWELL ❑GEOP14YEFCAL WELL A L POLL Bowe d' <br /> ❑DtffRMVON: <br /> NTENDEO USE T OF WELL @ONfTIIUCTION SPECIFICATION! 1 f A <br /> STRIAL t9qPIEN BOTTOM DIA,OF WELL EXCAVATION / DIA.OF CONDUCTOR CASINO_ D <br /> ❑ OOMESTICMRIVATE ❑GRAVEL PAC KMU_ TYPE OF CASINOISTEEq MVC _ DIA.OF WELL CAVING Q <br /> D PUBLICIMUISCIPAL ❑DRIVEN DEPTH OF GMUT SEAL Q D _ SPECIFRCATICN Ir <br /> rr❑ MOATIOWAG 1:1 arm OROUr REAL INSrALLEO BY GROUT GRAND NAME E <br /> 4J MONITORINGJ �� / GROUT SEAL PUI.LPEO: ❑ <br /> ❑Yr Ne CONCRETE PEDESTAL SY Ommm❑Yw ON. d <br /> AIMRb7r.bbTN_ _ /O++CD _ _-- LOCRING CHESTER BOXMTOVE RIPE s <br /> PROPOSED CONVTRUCTNONUDRILLING 1MFFHOO: MUD RWTARv AIR ROTARY AUOER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIV APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH BAN JOAQUIN COUNTY OWXNANCES,BTATE LAWS.AND RULES AND <br /> L <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY, HOIE OWNER OR LUCENB.[D AOENT'l SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OF THE WORK WHICH <br /> FOR W <br /> THIS PERMIT IV ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORIOMAN'I COMPENSATRQN LAWS OF CALIFORMA.- CONTRACTOR-1 HIRING OR EU&CONTRACTING SIGNATURE CERTIRES <br /> THE TOLLOWIMM. '1 CERTIFY THAT IN THE PEANCA OF THE VW FOR WHICH THIS PERMIT 11 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPWISATION LAWS OF <br /> CALIFORNIA.' THE APFUCAWF MUST CALL 24IN ADVANCE FOR ALL 1110MM INSPECTIONS AT 12011 490a92S. COMPLETE DRAWING AT LOWER AREA PIOVIDED. <br /> 0. <br /> PLOT PLAN ID.sw is Baalsl Rash_—'ro <br /> 1. NAMES Of STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYITEM OR PROPOSED <br /> U!. OUTUNB OF T1IE PRMRIT I.GIVING OIMENSION4 AND NOMM INACTION. EXPANSION OF BEINAGE DISPOM SYSTEMS, <br /> S. DIMENSIONED OU'LINF,B AND LOCATION Of ALL EXHITING AND PROPOSED S. LOCATION OF SMELLS WrIVINI RAOIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTLAEB.INCLUDING COVERED AREAS OWN AS PAYING$.DRIVEWAYS,AHD WALKI. ON THE PROPERTY OR AOJONFp PROPUITY. <br /> ...,... .... ., .. - .. .. <br /> : <br /> .41 <br /> E <br /> .il <br /> .......:. . <br /> 5 s ; . <br /> �.rL.P4 �'"IiCR"S <br /> DEPARTMENT USE ONLY <br /> - s <br /> AF ft~Mssylsd By Wts I NM <br /> O,md Impm"m BT_ • F Irwpsatrsn BY DNI■ � <br /> Oa glmthn t nwda BY O.I. <br /> - v <br /> ACCOUNTING ONLY-. AIDE FACE {� D 0 3�—7 <br /> I'm CODES FEE INFO AMOUNT REMITTED CFB71+ AW Pocavoo■Y DATE P@E4AITl1 - <br /> 3`�', <br />