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.PLICATION FOR WELL/PUMP PERMI? <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER(2V�E}N�-�2gCK70N, CA 95202 ORIGINAL <br /> NON-AEFUROAPLE PERMIT EXPIRES 1 YEAR FRIM DATE ISSUED <br /> IComplele In TripReslel <br /> APPLICATION 09 HERE BY MADE TO THE SAN JOAOUM COUNTY FOR A PFRMIT TO CONSTRUCT AND/OR INSTALL THE woW OESCRJRED. Tilr9 APPLICATION IS MADE IN COMPLIANCE VJTTII SAN <br /> JOAOLIM COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 115-3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. <br /> JOB ADORESSIOR APN! �j} ,I'1 � , CITY .} f r-1-c L PARCEL SI7,ElAPN/ <br /> OWNER'S NAME 'yC-L-� ADDRESS ''VL t� PHONE F Y- <br /> CONTRACTOR ran i S <br /> v l -S <br /> ADtr7Eee uc! -70q`!27 PHONE f- ![L-2 6E <br /> FUS CONTRACTOR ADORESS UC! CUONE! <br /> TYPE OF WELLJPUMP: ❑ NEW SHELL ❑ REPLACEMENT WFL4 ❑ MONrTORJNG WELL! ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f <br /> 11New 1-1ReP.Ir H_P_ DEPTH PUMP SFT FT. FIRST WATER LEVEL p <br /> IT YPE OF PUMP) <br /> ❑ <br /> OUT-0K 6'ERViCE V/ELL ❑ OEOFFIYfiICAL WELL! �GIL BORING 17 <br /> ❑DESTRUCTION: <br /> INTENDED ULE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTMAL ❑OPEN SO FTOM DIA.Of WELL EXCAVATION_ DIA.OF CONOUC TOO CASINO p <br /> Cl DOME STr/PRJVATE ❑GRAVEL PACK1917E TYPE OF CARINGISTEELII'VC_ OIA_OF WELL CASINO p <br /> ❑ PUBLIC/MVFJICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ,q <br /> ry❑��IRMGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F <br /> L'J MONiTOMNO GROUT SEAL PUMPED: Ely. ❑Na CONCRETE PfD#STAL BY DRILLER:❑Yee ❑Ne 5 <br /> APPROX,OEPTM LOCKING CHESTER 19OXMOVE PIPE �y 5 <br /> PROPOSED CONSTAUCTIORMIRILLING METHOD: MUD ROTARY AIR Fro TARP AUGER CABLE OTHER <br /> I HVWRY CERTIFY THAT I HAVE PREPAnED THIS AF"-}CATION AND THAT THE WOES(WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> REOULATIONS OF THE BAN JOAOUM COUNTY, HOME OWNER OR LICENSED AGFNT'8 SIGNATURE CERTIFIES THE FOLLONMJO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMFT 18 ISSUED,I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S MIRING OR SUIT-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLO CERTIFY SHAT M 1'}#E RE RFORMANCE OF TJiE WORK 1-0A WHICH THIS PERAAR IB ESSV£d.I BHAf:1 EMPLOY PERSONS SVROECT TO WOI7IMAN'/COMP'•Jf/A npN LAWS OF <br /> CAUFORf. A AHT MV/i CA 24 FbIJHS N ADVANCE FORA REOUN7ED INIIEC T`TO NS ATtf70/I�//JIt OM1'LETE DRA OAT LOWER AREA PPIYJIVI ED. <br /> PL07 PIAN R1•.vv rP Bt.1eJ Sea3• {-I 'te� <br /> I. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPFFITY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYBTFM OR PPOPOBED <br /> 2. OUTLINE OF THE PROPERTY,OIVMIO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNFS AND LOCAT"Of ALL EAIB'TTNO AND PFIOPOSEO I. LOCATION OF WELLS NATMN RADIUS OF ONE HVNOr%O FIFTY FT <br /> STRVCTVRER,INCLUDINO COVERED AP;FAB SUCH AS PAT".DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINMG PPIOPERTY. <br /> DEPARTMENT USE ONLY <br /> Acdl..11-A-a td By 00. + 1 ~ / A,r <br /> o-ut I..eo'-IL n BV D.I. P—P 1n.Pee ti..SY DNa <br /> Oe.t,i.:rlon I-rP tLo Rv Om. <br /> Comma+le- ✓ <br /> ACCOUNTING ONLY: AID! FAC! <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK/!CASH RECOVEO BY DATE 1`9MITNEAV7CE REQUEST NWEM INVOICE <br /> qD$6 l S' <br /> ?�D <br /> g �Pub tiealth Sery EOviro 173 (1;97) � <br />