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APPLICATION FOR WELLIPUMP PERMI <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERMS PAYMENT <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> P,O, BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA%ml388 <br /> (2091469-3420 <br /> MAR 13 1995 <br /> A BON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> SANJO.E LT"oUICOUNTY <br /> �� 7--U(J. PUBLIC HEALTH SERVICES <br /> APPLICATION IB ERE B MADE TO THE SAN JOAGUIN COUNTY FOR PERMIT TO CONSTRU(compleCTIAND/OR INn I STALL THE WOR(DESCRIBED.THIS APPLICATION ENVIRONMENTAL S MADE IN COMPLIANCE l 11 VWRHO A <br /> JOAQUIN COUNTY DOPMENT TR <br /> R 15.3 D T STAN,/D�ARJp�B�O�F 6 J A IN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNB /'✓�( V ' <br /> CITYJJ�� 7�PARCEL SIZE/APNE c//FF��++ ))// <br /> OWNER'SNAME//���� ADDRESS <br /> CO42 I L > VU <br /> CONTRACRACTOg1'[y/,VLt�IL � PHONEF <br /> ADDRESS ( LK 5'yI -tC-PRO <br /> p 8UB CONTRACTOR - ADDRF86/ I� � <br /> ' <br /> PHONE S-Sn <br /> TYPE OF WEUJPUIF' EW WELL ❑ REPLACEMENT WELL ��,��,,,,,,,{{{{{{��.��.I����I.� --�//��'��'//////''II'' , <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR MONITORING WELL 8 ��❑ OTHER <br /> ❑Na ❑ ❑ CR088-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL{ <br /> ITYPE OF PIMPa1r N.P. DEPTH PUMP SET_ITT. J <br /> FIRST WATER LEVEL <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL F O <br /> ❑DESTRUCTION: <br /> ❑ BOIL BORING B <br /> INTENBED USE TYPE OF WELL <br /> C SPECIFICATION{ <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM ��yy A <br /> ❑ DOMESTICMDVATE �&HAVEL PACK/SIZE Zlrz DIA.OF WELL G/STEP TION DIA.OF CONDUCTOR CABINO� <br /> TYPE OF Cg81NG/6TEEIJPVC <br /> ❑ PUBtIC/MVNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL—I � � DIA.OF WELL CASINO E <br /> O <br /> ❑ IRRIGATION/AG ❑OTHER GROUT III TON <br /> GROUT SEAL INSTALLEDBYR <br /> ONITORING GROUT SEAL PUMPED:glyr ❑No GROUT BMNp NAME- f <br /> APPROX.DEPTH / _ //'' CONCRETE PEDESTAL BV DRILLER:❑yr [IN. <br /> /' LOCKING CHESTER BOX/STOVE RPE JL W"4 5 <br /> R101OBED CONBTRIOTIONIDRBWNG METHOD: MVD ROTARY JL q TABLE S <br /> _�" IR flOTARV AUGER CABLE <br /> OTHER <br /> I HFREBV CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WOR(NAG A DONE IN ACCOgOgNCE HATH BAN JOAGVIN COUNTY ORDINANCES,STATE LAWS,ANO RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY, NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT 1S ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOq WHICH THIS PEgMrt IB ISSUES,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF <br /> CALIFORNIA.' T 1E APPICANT .�IWT ALL 24 IOISN IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT 1208)4gJ12y COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> slo x \ !T'Ni/ <br /> T111s� <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TTLHEENPROPERTYSoelel SCele_I •to/ 1 I� <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PR DMSM <br /> 3. DIMENSIONED OUTLINF6 AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. 8. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOINING PROPERTY, <br /> 1 <br /> �e <br /> c OI <br /> I . <br /> 1 I A ,�.(^a DEPARTMENT USE ONLY <br /> APPIlcncc <br /> lon Awted By /IJW <br /> G,ew Imo«[Ion By <br /> Oet° Pump Imp«non By <br /> D-tl-llon Iro Dete <br /> P«non By <br /> Det. <br /> Cammenb: <br /> ACCOUNTING ONLY: AIDI �� <br /> FAC/ / <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER <br /> o ,uu �1156 � �zq INVOICE <br />