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11, APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ? _ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 34 EAST WEBER AVENUE, STOCKTON. CA 95201388 <br /> (209) 468.3420 <br /> NOK-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ?S`� Z <br /> APPLICAi IOk IS HERE By MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TOtal <br /> CONmplete I 1 <br /> STRUCTANDIORINSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OrVISION. <br /> JOB ADORESSMR APN#, A Q r6 S- I LL,S is u R v CITY e' PARCEL BIZFJAP.+M55, <br /> _ �(•�(' <br /> C <br /> OWNER'S NAME ADDRESS C ONE#, �c [Z <br /> L t ` ADDREBS� I <br /> CONTRACTOR1-, � � L���,.,�'Qf��PHONE <br /> BUR CONTRACTOR ADDRESS LIO# <br /> TYPE WELLIPUMP: '�NEW WELL ❑ REPLACEMENT WELL ❑ MONfTORING WELL I ❑ OTHER_ <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS&CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> 0 New G Rapelt H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> RYPE OF PUMP) p <br /> ❑ PUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING - g <br /> ❑DESTRUCTION: <br /> INTENDED USE MAF WELL CONSTRUCTION SPECIFICATIONS � <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM f ''��V <br /> DIA.OF WELL EXCAVATION 1`�• Tj1A,OF CONDUCTOR CASING p <br /> ❑ DOMESTIC/PRIVATE �AVEL PACKIBIZE TYPE OF CASINO/STEELfPVC YG DIA,OF WELL CAGING ` <br /> ❑ PUBUCANUNICIPAL ❑DRIVEN f <br /> DEPTH OF GROUT SEAL _ SPECIFICATION rr77 R. <br /> X4RRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME V <br /> E <br /> 11 MONITORING ! GROUT SEAL PUMPED_Woo ❑No CONCRETE PEDESTAL BY LLEFL-❑Y. <br /> APP ROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE_ <br /> PROPOSED CONSTRUCTIONIDIELLING METHOD: MUO ROTARY, AIR ROTARY AUGER_ CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES <br /> AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE MI-LOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORT(FOR WHIC <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAIJFORNIA.• CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CEF?TIF�Ef` <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I @HALL EMPLOY PERSONS SUBJECT TO WORIMAN'S COMPOMATION LAWS OF <br /> CALIFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOumSD INSPECTIONS AT{2011 4ga4271_ COMPLETE DRAWING A7 LOWER AREA PROVIDETI_ <br /> Signed X C. _Tltle�d <br /> PLOT PIAN IDrew to Sa tel Sulo •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4_ LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR pFOPOSEp <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPAN@ON OF SEWAGE DISPOSAL SYSTEMS_ <br /> 3. OIMENMONEO OUTLINE.$AND LOCATION OF ALL EXISTING AND PROPOSED @. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PPO ERTy. <br /> r <br /> . .JUL... 8196 :.. . . <br /> 3r <br /> I�l1f3LlC - I T Fr�l/f c t <br /> DEPARTMFJIIT US[ONLY - .. <br /> Apptloellon Aaeeptad By p <br /> Dote Z ! Ates r . <br /> Grout IrnpeeHon By Iota ``G l J7 Pump Inspection By <br /> _Dots <br /> Dntruellan Inepeollon By <br /> 1 T 3 Dote <br /> Comments: �}� IVIn <br /> baes <br /> ACCOtVfnNG ONLY: AID# FACT <br /> PE CODE) FEE INFO AMOUNT REMITTED C EC /CASH RECEIVED BT DATE PERMITISERVICE REOUNT NUMSER INVOICE <br /> �r3� 1�a U 031 tJq <br />