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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI(;cS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209)488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. <br /> JOB ADDRESSORAPNI����`�c`1V�11 --£�i\�Q� '��.�e2. CITY��� L�4-��C^�'\ PARCEL SIZE/APN/ <br /> \^ c����\ ♦ <br /> OWNER'S NAME �\\CQ!1 -�"��\ \'\�=�Cw ^•`c"'� �.G,OGRESS PHONE I yQ\<_ <br /> CONTRACTOR a�\�!\:'tU\.T-L-�P 1''r ADDRESBQ-�Cu\C\b�--©�:a®��UCiGo1'aCo\mac PHONE/ <br /> ADORE88Sc�_�'�C_�P�_ �S\'tlfYf- PHONE I'\.�Y<-- <br /> TYPE OF WELUPUMP. ❑NEW WELL ❑REPLACEMENT WELL U MONITORING WELL Iy.��*\� ❑OTHER <br /> INSTAL ATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL/ J <br /> ❑Nen❑R.p.Ir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ITYPE OF PUMP) <br /> ❑OIfT-0E-SERVICE WELL ❑GEOPHYSICAL WELLS ❑ BOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑INDUSTRIAL 00 O/PSN BOTTOM DIA.OF WELL EXCAVATION �' DIA.OF CONDUCTOR CASINO "P'S\C� O <br /> ❑DOMESTICNRIVATE {[7'BIYtVEi-PACKMIZE�� '\ 'LLYPE OF CASINO/STEELIPVC \�C' ,�<\�I'-�C7 DIA.OF WELL CASINO D <br /> ❑PUBLX:/MUNICIPAL ❑DRIVEN DEPTH OF GROLR SEAL`4,- \PECIFK:ATION R <br /> GROUT <br /> C7 MONITORING ❑OTHER GROUT SEAL INSTALLED <br /> ❑Y- ❑Ne CONCRETE PEDESTAL BY DRILLER:[3Y- ❑Ne S <br /> APPROX.DEPTH ��^_> 1.-cY-• C'rl �y,• LOCKING CHESTER SOXMTOVE PIPE S <br /> PROPOSED CONSTRUCTION/DRIWNO METHOD: MUD ROTARY' AIR ROTARY io AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL RSGUIRm INSPECTIONS AT 120,81400-3422.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> D.I.\,��- <br /> .` �l`� PLOT PUN(Or—1.SORA.)Sub 'to <br /> 1.NAMES OF STREETS 11 ROADS NEAREST TO OR OUNDING THE PROPERTY. 4.'LOCATION OF HOUSE SEWAGE 018 SAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH 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 FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> .... <br /> . <br /> DEPARTMENT USE ONLY <br /> AppllO.tl.n A,,"t.d BY D.t. Ar- <br /> 6rovl Ir.p.OtlOn By D.t. Pump Imp.Otbn By D.t. <br /> DwvUetbn Irr.p.tlen BY D.t. <br /> Ceram-W <br /> ACCOUNTING ONLY: AID, FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECOVED SY DATE PE MITISERVICE REQUEST NUMBER INVOICE <br />