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;rte APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 888, NX EAST WEBER AVENUE,STOCKTON,CA 95201-SM <br /> (209) 4883420 <br /> _NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Trlpikate) <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPUCATION IB MADE IN COMPLIANCE VJrTH SAN <br /> JOAQUIN COUNTY DEVELOPMENTTITLE,CHAPTER 8.111 6.3 AND THE STAND OF SAN JOAOUIN COUNTY BC HEALTH SERVICES.ENVIRONMENTAL HEALTH DMRION. <br /> JOB ADORESS/OR APR,. I3L y�',Z(�P rT'V�'I�Gj- CITY./�Q�/-�n•+[� �J p..,PAARC,EL BIZE/APNO <br /> OWNER'S HOME a ,t _ADOREeS�J� /`fin Lam'Y Joh/Sa A t'W [-n2 PHONE A gFj'ypZ�4,�E 1"S <br /> CONTRACTOR l�I nlf+-}f„rf,�-{ I / V'U S.o T ADORESS[��/j_,Sta+l j UCI 421h %gNES/ <br /> SUS CONTRACTOR T5 A-NF-. - FXOIGIa�o h ADDRESS ^S 1�f - I UCa - PHONE Ir2zz- <br /> T_YP%OF WEL)PUMP., NEW WELL ❑REPLACEMENT WELL ❑MONITORINO WILL F ❑OTHER <br /> ❑INSTALLATION ❑WELL eYSTEM RE►AIR ❑Cnos"ONNECT REPAIR JF/GY��VAPOR EXTRACTION WELL I V <br /> TYPE OF ./ <br /> 13u-0 RSp.I, H.P. ' S I�krt <br /> DEPTH <br /> PUMP BET R, fIRST WATER LEVEL ���� �a0 .\ U <br /> PUNT% (r <br /> ❑OUT-OF•SERVIOE WELL ❑GEOPHYSICAL WELL f ❑ SOIL BORING S <br /> ❑DESTRUCTION: <br /> I <br /> INT---D----' ;�==" -� CvH:iRUC iiON pPECiFIG ATIONe A <br /> ❑INDUSTRIAL 13 OPEN BOTTOM DIA.OF WILL EXCAVATION _SS DIA.OF CONDUCTOR CAGING�� c <br /> ❑DOMESTIOIPRIVATE ❑GRAVEL►ALK/BIZE TYPE OP CASINO/STEEUPVC TUG DIA.OF WELL CASINO <br /> ❑PUSUCAAUN"'PAL ❑DRIVEN DEPTH OF GROUT SEAL x�—+ 10, /� // SPECIFICATION SGlfe.(�.4/D <br /> p0 <br /> 1 WWOATION/AO jo OTHER GROUT SEAL INSTALLED Bllk�'Nt OROUT BRAND HAMS E <br /> MONRORINO GROUT SEAL PUMPED:❑Y. ❑N T-- CONCRETE PEDESTAL BY DNLLIn:❑Yw ❑N. S <br /> APPROX.DEPTH LOCKING CHEeTER BOXMOVE PIPE <br /> /11'' }},,LE f±-� F <br /> PROPOSED CONSTRUCTIONIMLLINO METHOD: MUD ROTARY AIR ROTARY <br /> AUGER�' HW,Na.SGASI OTHER <br /> 1 HEREBY CERTIFY THAT 1 HAVE MEPARED THIS APPLICATIONAND THAT THE WORK WILL BE DONE IN ACCORDANCE MTN SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULE$AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S WONATURE CERTIFIES THE FOLLOWIFXI:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT If ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CAUFOMWIA.'CONTRACTOR'S HIRING OR BUB-CONIRUCTINO BIONATURE CERTIFIER <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY FERSONB SUI JECT TO WORIOMAN'S COMPENSATION LAWS Of <br /> CAUFORMA' THE <br /> ANT M T CALL 24 HOW IN ADVANCE POLL ALL REOUMRSO INSPSCTIONe AT 122.051/4".34/27,COM,sP'.LETE DRAWING AT LOWER AREA PROVIDED.�7 <br /> elprW X F'Sb-'i TIt1.Se"6;1'S'I2'T�C•-iCo(oAI.S'1 D.t• Id�.�y- <br /> PLOT PIAN to'—'.a".)eod. Ia <br /> 1.NAAAER OF STREET$OR ROAD&NEAREST TO OR BOUHDINO THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NOFrTH DIRECTION. EXPANSION Of SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY n <br /> STRUCTURES•IMLU04NO COVERED MEAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> SOUTH CENTER STREET 3 <br /> aFUIN,r uloaupnlp.- <br /> kLkm <br /> nll flpUf!uo[S -Ixxx{f 14nM,IiYF1 <br /> fN <br /> e_� � wO�^umuw.n�N mwlrx:wra l.ue,rlar, <br /> 11.lo a•slx+ nln.ufx�uac r ras n s • sMf xN w'�^NX,Inn w.0 Iwsx.x,Mx, <br /> su.E aro rauxxnM,luM uNlw.wNs <br /> ►. <br /> 'J <br /> flw,a l I <br /> CwEE <br /> Z+�W f <br /> Etl <br /> SITE MAP <br /> ' -- •- nsie - - •'IawE 2 <br /> /• C OFPAA RENT USE ONLY /l, / 2 <br /> Applb.lbn A~.d By / I f I V Oxl. /V rJ' Mr <br /> OroN Nrp..11M By D.I. Pmp Inxpwll.n ey D.t. <br /> D--.6nIn.p�wsl.n^By D... <br /> C.mm.nlf• v I l 51. lk.l e L <br /> AGCOUNTTNO ONL11 AID, FACS <br /> PE CODES FEBINFO AMOUNT REMITTED OHECK,ICASH RECEIVED BY DATE ►6vAT/Sq VICE REQUEST NUMBER INVOICE <br />