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APPLICATION FOR WELLIPUMP PERMIT -z- <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION/ <br />P 0 BOX 368, 446 N. SAN JOAQUIN ST, STOCKTON, CA 96201.388 <br />(209) 468.3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Ca piste M TrIPNeta) <br />APPLICATION 18 HERE BY MADE TO THE BAN FOADUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOFK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br />JOAOUN COUNTY DEVELOPMENT TITLE, CHAPTER 8.1116.3 AND THE, S'TAINOARDS OF BAN JOAOUN COUNTY PUBLIC HEALTH SERVICEB. ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADOMSBIOR APNl� j D9 W. (6,,r� µJOY C� S <br />/� � /�'' j PARCEL BREfA1NI F^�� N� ` <br />OWNER'S NAME 1`� &rV- IIxyr, ��I'� ADORE88 j h �.Q PRONE/ 5'3 y31 J-Zw7g< <br />CONTRACTOR�nc AODM ES �- W 1"`` � LIC! - <br />SNE • S <br />SUS CONTRACTORADORE8 <br />�,.../ r, PHONEt <br />TYPE OF WELLM/MF. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL! y�OTNERsci 6 L ITT -71 <br />11 INSTALLATION ❑WELL SYSTEM REPNR ❑ CHOSS-CONNECT REPAIR /❑ VAPOR EXTRACTION WKl <br />RYPE OF PUMP) ❑ N— ❑ R.pw, H.P. DEPTH PUMP SET----". �,.,FIIRST WATER LEVEL 0 <br />13OUT-0E-SE mE WELL 13OEOP"YSICAL WELLt �I SOIL BORING W V'[: <br />❑ DESTRUCTION: , \ ! <br />INTfNOm USE TYPE OF WELL CONSTRUCTION aPECMK:ATIONt II A <br />❑ NIOUBTWAL ❑ OPEN SOT -TOM DIA. OF WELL EXCAVATION g OIA. OF CONDUCTOR CASINO D <br />❑ DOMESTCAWVATE ❑ GRAVEL PACK/812E TYPE OF CASINO/STEEUPVC_ �� DIA. OF WELL CASINO Nei D <br />❑ PUBLIC/MUNICIPAL ❑ DWVEIN DEPT" OF GROUT SEAL.. r�IS ) SPECIFICATION , 4 1 A <br />❑IWWATION/AO ❑OTHER GROUT SEAT. INSTALLED BY k i �r GRGVT BRAND NAME Ahn �-f+6,K1 <br />13MONITORm GROUT SEAL PVMPED: Y.. ❑ RK <br />N. CONCRETE PEDESTAL By DLFR: 13v. <br />APPROX. DEPTH LOCKING C STER DOXIWOVE OPE�— S <br />PROPOSED CONtTRMTION/DISWNO METHOD: MUD ROTARY AIR ROTARY AUGER ✓ CABLE OTHER <br />1 HEIIEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN JOAGUN COUNTY ORDINANCES, STATE LAWS, AND INREB AND <br />REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT M ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S "NNW OR SUe•CONMACTNO SIGNATURE CERTIFIES <br />THE FOLLOWING: ' 1 CERITIPY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PEWNT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WOIIONAM't COMPENSATION LAWS OF <br />CALIFORNIA T APNCAN{\/T MWT CALL M HOVM N ADVANCE MR ALL MOMM NfNCTONt jAt 460614664462. COM/RETE DRAWING AT LOWER ATEA FM <br />t14n.M % � 1 \ �\M.� TItN '�(IQ J r ,'�S'�Q� 1ti1f 1U �QY'�) O•t• � �� <br />������777 PLOT PLAN tOr—In S.A.? BeW • to �— <br />1. NAMES OF STIIEETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR pOPOSED <br />6. GAMES <br />OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTINO AND PROPOSED S. DATION OF—If Wrtuw ..rw.. ne ...�........�.. ....., ._ <br />DIFAMENT USE ONLY <br />4 RT (/ r <br />Appl.•Ibn AewPIM a on.�11.. JJ A,.. <br />Greut k pP l.n ey . L t 'e D.I• � 5 P—, krP..Ben ey <br />D.e. <br />o.•Inwelen E+P..II.n <br />by <br />ACCOUNTING ONLY: <br />ANIS <br />FACE <br />PE CODES FEE INFO <br />AMOUNT R6A1TTm <br />CHECK#ICAGN RECENm By DATE <br />FEMBT/t91VICE MOUNT NUMBER INVOICE <br />35-0 1 <br />QD7 I S <br />- - <br />Rec,—ed by Date Receipt No f'e/rmt No Issuance Date Marled DelivereG <br />_.. --_.. _....__..._.,.�.....,.�.. .GTI1 c ue7FI7T]w AVP. P.O- Boz 2009 STOCKTON, CA 95201- <br />