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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES L / <br /> ENVIRONMENTAL HEALTH DIVISION }� �� <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 �`VI <br /> (209)468-3420 <br /> G_v NiN-REFUNDABLE PERMIT EXPIRES 1 TEAA FROM DATE ISSUEII <br /> V (Complete IR Trblkalel COPY <br /> fCATION IS HERE BY MADE TO THE CAN JOAOUIN COUNTY FOR A PERMrr TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE 1N COMPLIANCE WITIt SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115,3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AOORESSMA APR# / i r- CITY PARCEL 81ZEJAPNR ' <br /> OWNER'S NAME41,C OPIL' S(` / <br /> ADDRE88 /+y� ♦ PHONE/_�6l�� <br /> CONTRACTOR r �- ADOREBS V ��/ / UC# ' ,f U3PHONE/ <br /> RUN CONTRACTOR ADDRESS IJC# PHONE# <br /> TYPE OF WE MPI ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N <br /> ❑OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL E ./ <br /> ❑Now❑Pp* H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O <br /> IT YPE OF PUMP) <br /> ❑ OUT-OF-SERVN:E WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORNO �g <br /> � <br /> ESTRUCTIONrF- <br /> v <br /> IRIENDEO USE TYPE OF WETJ- CONSTRUCTION SPECIFICA IONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑ DOME811ICIPRVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC DIA.OF WELL CASINO O <br /> ❑ PUBLIC/MUMCMAL ❑DRVENI DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑-IRRIGATIONIAG ❑OTHER OROUT SEAL INSTALLED BY OIIOUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PIMPED: [IV. ❑N• CONCRETE PEDESTAL SY GRILLER:❑Yr [IN. 5 <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE*1fBY CERTIFY THAT T INANE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE TH ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAGUIN COUNTY, HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERI'ORMANCE OF T14E WOR(FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIMNO OR SUBCONTRACTING SIGNATURE CERTIFIER } <br /> THE F,= 'I CERTIFY HAT IN RMANCE OF THE WORK FOR WHICH THIS PERMfT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPINSATION LAWS OF <br /> CALIPORNSA T MUST A URSINAbVANCt FOR ALL REGUIRED INSPECT10 T 12001 400 COMPLETE DRAWING AT(OWER AREA RiRO ED. <br /> ROT RAN ID.wv to Ra■I■1 Se■1• to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 1. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br /> 2, OUTLINE OF THE PROPERTY,OIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED ■. LOCATION OF WELLS WITMN RADRIN OF ONE HUNDSZD FIFTY Ff. <br /> STRUCTURES,INCLUDING COVERED AREAS SACH AN PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> u <br /> ..x:75 <br /> r <br /> ro <br /> ..... ... Zvi <br /> t�1=C-MAY 20 <br /> dV�a. <br /> s <br /> � 1V 8LJC <br /> QUA: EALN SF <br /> S <br /> IkQNME. AL.HERi,RVI('1='• <br /> tvl= <br /> 1 <br /> - DEPAATMMlr USE ONLY <br /> Applla■tlen A•e■pl•d to D■l• v M•■ � J <br /> Oreu1 kwpwtbn ST _ b■1• Pimp Inrpeaelen eT D■!• <br /> ' D <br /> O.ntrtmlbn lrwPecll�V �, �`'/G(/j/L'L-/L1 D.ta <br /> Cammsk■: <br /> r <br /> ACCOUNTING ONLY: AID# FAC! <br /> PE CODES FEE INFO AMOUNT REMITTED NEC ASH RECEIVED BY DATE PERMITISERVICt REGUEST NUMBER INVOICE <br />