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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX U%304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209)466.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Camplats in TripButs) <br /> APPLICATION 18 HERE BY MADE TO THE BAN 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 9.1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> uo Parc.l <br /> JOB ADDRESMR APNS Ni✓�or u✓ of 5.G-4, f,LaL�40, CITY 5'Etx-k. PARCEL BIZFJAPWI <br /> /�� <br /> ONMERV NAME �^"1�r A"$ ADDRESS / PWONE <br /> CONTRACTOR_-1pA.G'ge- Lx',V.rOnrnc,n�-al �rO.��I ,ynC, ADDRESS 11315 Svnr)jQ Gpld���CJ( IJC/ LZG G2G0 PHONE/[q(b)666- <br /> SUB <br /> 66' <br /> .r1.0 Correa �r4r457H2 zsrD <br /> ellecorrrnACTORf{:�ai e 11 Lull;w FhNvn neh{ I (FIM) <br /> ADDRESS P.O.pox 7131 , uco 677 m? PHONE,MV.)Bsz <br /> W�C k. q571+1 95s6 <br /> TYPE OF WELLIPUMP. ❑NEW WELL ❑REPLACEMENT WELL MONTTORINO WELL In�8 ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL I J <br /> (TYPE OF PUMP) ❑N.w 13R..w, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> ❑OUT-oF-SERVIOE WELL ❑GEOPHYSICAL WELL I SOIL BORING B <br /> ❑DESTRUCTION: 1 <br /> INTENDED USE ELL OF WELL CONSTRUCTION SPECIFICATIONS <br /> 11n DIA.OF CONDUCTOR CASINO uQ D <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION <br /> ❑DOMEBTIC/PW VATE ❑GRAVEL PACKIWE TYPE OF CASINO/BTEEL/PVC DIA.OF WELL CASINO Z D <br /> ❑PUBLICNUNIOIPAL ❑ DEPTH OF GROUT SEAL KAx of 35 r SPECIFICATION NA p <br /> ❑IIWOATION/AO OTHER GROUT SEAL INSTALLED BY PTI IL&e (H DE) GROUT BRAND NAME Parlk.lc! C-n + E <br /> moHITORINGO GROUT SEAL PUMPED:❑Yr <br /> M. CONCRETE PEDESTAL S'/DRILLER:❑Vr IdLN. 5 <br /> APPROX.OF/TN ��'�T C, S5{{..��,kz >/ <br /> LOCKING BNESTER-DOk/SFOVERPE /� S <br /> Hplawslr <br /> PROPOSED CONSTRUCTON/DMWNO METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br /> I HE9ESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT 10188UED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.'CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOMC FOR WHICH THIS PERMIT I8 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' T ANT WT CALL b POW IN ADVAMCi FOR ALL REQUIRED PE AT 12w1IMJ427.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> ew�.ex � TItI. �1"tY �vl{iSf D.I. x/23/97 <br /> PLOT PLAN W—to 9".)Sa.I. 'to <br /> 1.NAMES OF STREET$OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWAOE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK$. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> I: ... <br /> - .. :.. <br /> .. ... .. <br /> I: <br /> DEPARTMENT USE ONLY <br /> Appll—1 n Aae.pt.d By�V 1_J 1i`T G�� O.t. �1 .� Ar.. <br /> Grant Inp.ptlen BY D.t. P—P I-p-d-BY_ D.t. <br /> Drtn tbn Inpe"t BY D.t. <br /> Damm.nt.:-_ 1-h-e.,-1-5 r�Wrok�bla ✓r►�tt �' (ogto�(p SV x622 w� v�tcl 109 roRv�)-a455' . <br /> ACCOUNTING ONLY: AIDI FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH CBVED■Y DATE ►BKPT/SERVICE REQUEST NUMBER INVOICE <br />