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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON,CA 95201-368 <br /> (209)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CompNtf In Trlpl-HERR) <br /> APPLICATION 16 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> 4,ry C�nJiZ-R- C{A'CLL Crry %UGk/(/N PARCEL SIZE/AM# <br /> JOB ADDRESSOR APN# �1T 2G>r <br /> /1.� ADDRESSZ' 'r�✓L RHONE# <br /> OWNER'S NAME/ 1R' M / AN-3 15L G'• yt�Zd <br /> 2T':S 1-r i Z rJ1 P rYa, C'� C5��,p 7 1,,, <br /> CONTRACTOR <br /> WLST /�RZ T ADDRESS .� e1 OVA' UC�j v� PHONE I� /G �TD �L� <br /> ADDRESS LIC/ RHONE A <br /> SUBCONTRACTOR <br /> TYPE OF WELLIPUMP, ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL# ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# J <br /> ❑New❑F-1, H.P. DEPTH PIMP SET----FT. ppFIRST WATER LEVEL {k'JCZCts�c <br /> (TYPE OF P1MP1 ❑OUT-OF-SERVICE WELL (3 GEOPHYSICAL WELL# pd SCIL BORING'I( ' - GU/S B��JJ <br /> DESTRUCTION: �1'• I j&,4ty5t S k 141 t&n1LY)S h-z!5 GV <br /> A <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑INDUSTRIAL ❑OPEN BOTTOM D <br /> ASING/STEEUPVC DIA.OF WELL CASINO <br /> TYPE OF C <br /> ❑DOMESTICIPRIVATE ❑GRAVEL P4CKI6IZE R <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑OTHER GROUT SEAL INSTALLED BV GROUT BRAND NAME E <br /> ❑IRRIGATIONIAG CONCRETE PEDESTAL BY DRILLER:11ey <br /> V ❑No S <br /> ❑MONITORING GROUT SEAL PUMPED:❑Vey [IN. <br /> LOCKING CHESTER BOX/STOVE PPE S <br /> APPROX.DEPTH <br /> OTHER <br /> PROPOSED CON$iR11CTION/DPoWNG METHOD:MUD ROTARY AIR ROTARY AUGER CABLE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 16 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA. j,NE APPUCAN(MUST CA 34 NOURG IN AD�VrANCE FOR ALL REOUIRED INSPPEC TInON$AT 1]091,{4fBJ1(2/] COOMPLETE DRAWING AT LOWER AREA PROVIDED. (' <br /> /J Tllla Pr- <br /> PLOT <br /> PLOT PLAN(Dr to Se/lel Seela�_'to <br /> 14 0 4.LOCATION OF"OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED/.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. <br /> S�L stn .E t .Tlys <br /> I yytr ,�ti�. Lif <br /> Coo- ILvLo c)( Secvl ce_ �c(��• <br /> 3.1 90 ,4 L)-1-0 Ce'v T-L--2 C/Rc tG �1CJro c%�� 10T�ori�4s <br /> klju Cr'giu c s otDs MoeI L-'E �PrcrpSl'�S('.J( 0 <br /> S <br /> DEP TMEHT USE ONLY <br /> Dele Are/ <br /> Appllo/llen Aeeepled BY I — <br /> Oro�t Iropeetlon RY <br /> Dete P'mP Irop—l"BY DNe <br /> Dete <br /> D.11-11on Iropectlon By <br /> Cemmenb: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED By DATJE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> �tb i5 7n1 /U 5 <br />