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APPLICATION FOR WELLJPUMjI PE ` <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 _ <br /> (209) 468-420 <br /> 11011-REFUNDARIE PERMIT EXPIRES I TEAR FROM GATE ISSUED <br /> Ica"lata%Trlpkatal 'i <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMrr TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT'TITLE.CHAPTER I S.3 AND THE,S,.T,ANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH N, {h} -•�.'yy' <br /> JOB AbbREBS/OR APNI (lJZ I +� 1�„K S>L Ckk pca.4 CITY p IL K��"l PARCEL 812VAPN O ~"lD v 1 <br /> OWNER'S NAME Cr 5�•�; `^^'�i� v ADDRESS 1. E 4� 1��r. '!I r1�Qj}�,� of\VT.+ PHONE <br /> CONTRACTOR 4 L 1T>t S ot'Z 3. *4 L�.�• AIM. I l�Q''ZV'k-j 0Ci1 Vh -,'k1�___IC- PHQNE 15��' Z-2-7- <br /> BUS CONTRACTOR V L� r' IU AOORESS 9CX5`- �-1-Q �u __bMU.,�f Q� P1lONEf �GJ. <br /> OF MP �HNEW WELL ❑ REPLACEMENT WELL ONITORITM WELL# ❑ OTHER <br /> [3 INION STALLAT ❑ WELL SYSTEM REPAIR CROSS-CONNECT REPAIR - ❑ VAPOR EXTRACTION WELL f 1 <br /> c <br /> ❑N.r.O R.pW H.P. DEPTH PUMP SET FT: - FTRITWATER LEVEL G <br /> '3 <br /> (TYPE OF PUMP/ <br /> © tlUT-0FBERVICE WELL ❑ GEOPHYSICAL WELL#-! BOIL BONING B <br /> ❑DESTRUCT1pH• <br /> Y <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECBHCATION; -• 1'A A <br /> m <br /> ❑ tHOUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO A D <br /> ❑ DOMESTICMRlVATE ©GRAVEL PACKIIRE TYPE OF CASINOISTEETIPVC DIA.OF WELL CASING �• tl <br /> ❑ PUBM MUNICIPAL ©DRIVEN DEPTH OF GROUT SEAL •i SPECtMATPON <br /> ❑ IaIGATIOHRAO OTHEN GROUT SEAL;RSTAU"BY GROUT BRAND NAME f <br /> MONITORIHOf LOCKING CHESTER SOXAYT <br /> GROUT SEAL PUMPED:�Yw ❑Ns;, CONCRETE PEDESTAL BY DRRLER.0 Yw I lfe S <br /> lir✓ �k f <br /> APPIIOIL DEPTH OYE RIPE S <br /> PROPOSM CONSTRUCTRONII)MA IrG METHOD.- MUD 1WTAJIY AIR ROTARY AUGERCABLE OTHER <br /> I HE-EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAH JOAGUN COUNTY ORDINANCES.STATE LAWS.AND RULES AMD <br /> REWA ATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S MPIATURE CERTIFIES THE FOLLOWING''T CERTIFY THAT IN THE FERIORMANCE OF THE WORK FOR WHICH <br /> THIS FERMI.IS ISSUED.P SHALL NOT EMPLOY PERSONS SUBJECT TO WOR%MAN't COMPENSATION LAWS OF CALIFORNIA.�h CONTRACTOR'S HIRIM OR SUB-CONTRACTING SIGNATURE CMWKS <br /> THE fOLLOVVING; '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMTT IB ISSUEO.'I SHMl EMPLOY PERSONS SUBJECT TO WommAN't COMPENSATION TAWS OF <br /> CALIFORNIA.' THE APPLICANT2A HOURS IN ADVANCE FOR ALL REOUIR�INSP[CTIONG AT 120SI142-2422.I COMRJETE DRAWING AT LOWER AREA PROVIDED. <br /> MUST <br /> 1 �S <br /> 17 S1lrwd X TRNJ -! -_ d�A/ __O.t. <br /> PLOT PLAN Or~t.60061 <br /> 1. NALIES Of u."%EIB OR ROADS NFAREBT TO OR BOUNCING THE PROPERTY. 4. LOCATION OF"CURE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> ;. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. _j: EkPAMWN OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINE.*AND LOCATION OF ALL EXIBTNG AND PTOPOQED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCn REB.INCLUDING COVETED MEAS SUCH MT PATIOS.TIRVEWAYB,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> %w } <br /> i <br /> ?, ..-'- warn na r.aa t.rrrrcol sx-i ci <br /> t <br /> i.. <br /> ' + srxr r Sac.utol <br /> — <br /> .. - --- <br /> I I I • <br /> Fl <br /> ..:.:: <br /> �r°�ARTMEILT USE ONLY A <br /> Applte.tlen AvoWed BY <br /> cote- <br /> B► <br /> Grein Mnpe.tlen . O.t. . <br /> D.0 ' <br /> De.tnrtl.n Ivpen;9 <br /> Cnrernernr r KN <br /> ACCOUNnNG ONLY; AID# FACT <br /> .I 34 a <br /> FE COom FEE INFO AMOUTT Ill"TTED CHECKOICASH R ' aA - OATS �, PUMMITISERVICE REQUEST NUMBER INVOICE <br /> o f <br /> . if <br /> tt <br /> _ .. .•..-n��. t.w.... 17'i if pT r _ , - .. / <br />