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14 APPLICATION FOR WELLIPUMP PERM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SHWES PAYMENT <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9520138MAR 13 1996 <br /> (209) 488.3420 SAN JO,i UIN COUNTY <br /> ENVIRONMENTAL LH i SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED H SER�I����faN <br /> LTH <br /> (Complete In Triplicate) <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAI <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/O•R AAPN! CITYL,<C�/f�L� �}/� `E- PARCE.LL 8112�EIAMO <br /> OWNER'S NAM L r-�T1C ADDRESS / J `2���v- ` �1 nr,-l' PHONE R <br /> CONTRACTORNaM t[1_ AD EB cGI��I LICec (y��q'EE ?0/- <br /> /- <br /> 1� BUB CONTRACTOR gJw ` Z [�I Cr{ PHONE J�-lira <br /> TYPE OF WELLIPUMP: EELL W WELL ❑ REPLACEMENT WELL )RIMONITORING W / u}ZO)l ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR SFT ❑ VAPOR EXTRACTION WELL# d <br /> ❑N.11 RoPsh H.P. DEPTH PUMP SET ...FT. FIRST WATER LEVEL ~ C <br /> ITYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL e ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION {�rI DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/PRIVATE '9CRAVEL PACK/SIZEMZ TYPE OF CASING/STEEL//'PV(C/ Ty� �ry}yJ�3�DIA.OF WELL CASINO U 0 S <br /> ❑ PUBUCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL'TZ��iC72 NSPECIFICATIONR <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> PMONITORING /� _I ' GROUT SEAL PUMPED: El Y. [IN. CONCRETE PEDESTAL BY DRILEER:❑Ya C(Ne S <br /> APPROX.DEPTH, 1 l� T LOCKING CHESTER BOXWTOVE RPE S <br /> PROPOSED CONSMMnON/WSWNG METHOD: MUD ROTARY AIR ROTARY_ AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RUM AN <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICI <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIPE <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS 0 <br /> CALIFORNIA.' T APPLICANT MWT ALL 211IOWS IN ADVANCE FOq ALL REQUIRED ININ{i 2f. CO�MR.EFE DRAWING AT LOWER AREA PROVIDED. <br /> Blerd) o,(.(� TIt1. FA; IO D.,. <br /> PLOT PLAN IDrwv to eo.ls)owl. teL <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL 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 /> rye, <br /> CENTCR �R���` <br /> D� I <br /> N _ ' <br /> (n <br /> I I <br /> i <br /> A <br /> VLW�W'A`_ (� ^ n L DEPARTMENT USE ONLY <br /> APPA atlen AccWted BY '�V.//AV, /L/JI/t D.b • ` � Ora <br /> Gann linptwtlon By Did. Pump Iapatlon By Due <br /> D.,,.tlon Inepatlon BY /D.t. <br /> Comments: ca-Q.I T O V`�-'•`,►� � Q V►.l�C.� !/� l.1lT — �-/�/ , �' l J , <br /> ACCOUNTING ONLY: AIDS FAC# <br /> t <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK!/CASH RECEIVED BY DATE PFRMITISERVICE REQUEST NUMBER INVOICE <br /> � ct-7714yL <br />