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,�•+ , 80 -(eO L3 - B <br /> { 1 APPLICATION FOR WELLIIIUMP PERMIT <br /> °..i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES` <br /> ENVIRONMENTAL HEALIH DIVISION <br /> PA BOX 388, 304 EAST WEBER AVE E, STOCKTON, CA%20f.M D <br /> 1209) 469.342 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 EAR FROM DATE ISSUED <br /> (Complots in Trip oto) <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/on NSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE wrrH SAN <br /> JOAQUIN COUNTY DEVELOPMENT tTITLE,CHAPTER 9.1 115.3 ANp}/ `{E_STANDARDS OF SAN JOAQUIN UNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADDRESSOR APNN 2 J 15 Iv CCS(4 �"W' , 5�+. CITE �[—t'JrJ�/Z PARCEL 61iElAPNN <br /> OWNER'S NAME Q Cl I_j dp c AD Q, .t7 <br /> '�r�.cSl _&.e/5Nt K I c � / FHONEN <br /> CONTRACTOR r _���I0001rAJ�?Jvt ,.1���,ADDRESS � W In (wJLL4vl LION v7 �ZL,y�pF{ONE N �� • ���' <br /> -E�eR504-1-1111( En4i ��.. <br /> ADDRESS IJCM <br /> f� 4 A– PHONE! GS' �I <br /> TYPE OF WELLIPUMP: ❑ NEIN WELL 11 REPLACEMENT WELL MONITORING WELL#_"2 l q 11 OTHER L 41 .1 J <br /> 11INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNEC REPAIR ❑ VAPOR EXTRACTKZN WELL! SSI E'j5 T J '•.J <br /> (TYPE OF PVMPI 13New❑Repair H-P. DEPTH PUMP SET FT. FIRSTWATER LEVEL O <br /> ❑ OUT4OF-sERviCE WELL ❑ GEOPHYSICAL WELL N ❑ SOIL BORING B <br /> ❑DESTRUCTION; 1 - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION gPECIFICATIONS.SPECIFICATIONS. A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION O r T DIA,OF CONDUCTOR CASINO D <br /> ❑ OOMESTIC/PRIVATE GRAVEL PACK/SIZE 1'l TYPE OF CASINGISTEELPVC DIA.OF WELL CASINO f2 <br /> 11N <br /> PUSLICMUUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL I SPECIFICATION 5,-A Q U C n <br /> ❑ IRRIOATIONIAG 11OTHER GROUT SEAL INSTALLED BY S (]IY[.tiv✓� GROUT BRAND NAME E <br /> W MONITORING I GROUT SEAL PUMPED:xYe. ONO CONCRETE PEDESTAL BY DRILLER:14Ye. (JN* S <br /> APPROX.DEPTH_ ~75, , „ LOCKING CHESTER B XISTOVE PIP£ S <br /> PROPOSED CONSTRUCTIOWDMLLING METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER <br /> I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOPK WILL BE DONE IN AC ORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULER AND <br /> REOULATIO THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFI S THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORT(FOR WHICH I <br /> THIS MIT IB IS SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS F CALIFORNIA,' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE LLOWIND: CERTIFY THAT IN THE PERFORI CE 011 WORK FOR WHICH THIS PERMIT 18 IS UEO,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIF IA.' TME CANT MUST A 4 NO N A N FOR ALL REQUIRED IN s< TIDNS AT 2091 4etJA2f, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Sloped X TIO o Date3 . <br /> PLOT PLAN(brow.to Soolel Scala 'to <br /> 1. NAMES OF STREETS OR ROADS NEARE OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I <br /> 2. OUTLINE OF THE PROPERTY,MVINO DI MONK ANp NORrH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> a. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS Of ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> 711.... .. .. <br /> DEPARTMENT USE ONL <br /> Y . <br /> ApPlloalron Aeeopled By <br /> Dale <br /> Oreu1 Ir»pecllon <br /> by <br /> Data RnnP In6pectlen By <br /> Oeatrpetion lrnpe rlon By - <br /> Dots <br /> Comment ~ t r^ <br /> s• <br /> ACCOUNTING ONLY: AID! FAC! <br /> t <br /> 1 <br /> FE CODES FEE INFO AMOUNT REMITTED CHECKNICASH RECEIVED BY' DATE <br /> PERMTISERVICt REQUEst NUMBER INVOICE <br /> /9 <br /> 1 <br /> Pub.Health Serv.-Enviro.173(3195) �y A <br />