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pAYMEINT <br /> ,ePPLICATIO i`FOR WEL PUMP PERMIT 1' —(= ,EIVE® V <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y�l <br /> F — ENVIRONMENTAL HEALTH DIVISION . - — — OCT U 2 1998 <br /> a 304 EAST WEBER AVENUE, S OCKTON, CA 85202 <br /> (209) 4GB-34 0 8iA JOAQUIN cUUNTY <br /> NUN-REFUNDABLE PERMIT EXPIRES 1 EAR FROM DATE ISSUED <br /> ENV SERVICES <br /> (CempMts le TFIP ah) MAL <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAQUIl)COUNTY FOR A PERMIT TO CONSTRUCT AND/O INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITII SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111.6.3 AND THE STANDARDS OF SAN JOAQUIN OUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMBION, <br /> I - �- I <br /> JOB ADORESS/OA APNA CITY PARCEL BIZEJAPNB <br /> OWNER'S NAME ��1111rr. ��. ADDRES \`�•IC:fffiQ6. <br /> ��g a• HONE f ,Sb <br /> - - S <br /> CONTRI.CTORU-.)��m� �• ��� ADORES QaC'1C �: LIC `/ �PHONE <br /> SUB CONTRACTOR �� ADDRESS t1C# PHONE I <br /> TYPE OF WELLMUMP: ,❑y NEW WELL 1:1 REPLACEMENT WELL IISMONROWNO L/�.� ��7�(p 13 OTHER <br /> Ll:l INSTALLATK7N - L] WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR 11VAPOR EXTRACTION WELL I i <br /> ❑New❑PAP* H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMPI ft <br /> I L3OVT-0SE <br /> F-OFWELL ❑ GEOPHYSICAL WELL I a----1 BOFVNO a <br /> ` r <br /> ❑DESTRUCTION: i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATEO S A <br /> ❑ INDUSTRIAL 1 ©OPEN BOTTOM DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO Q <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CA8INOJSTEc%95'5� DIA.OF WELL CASINO D <br /> ❑ PUBLIOJMUNICIPAL ❑DRIVEN I DEPTH OF GROUT BEAL SPECIFICATION S <br /> .❑....�IMOATKINIAG ❑OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME I E <br /> LI�'MOMTORING IGROUT BEAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLER:13F-Yee LJ Ne 5 <br /> APPROX.DEPT" t LOCKING CHESTER 0)(STOVE PIPE I S <br /> PROPOSED CONSTRUCTIONMAILUNO METHOD: MUD ROTARY AIR ROTARY AUGERCABLE OTHER <br /> 1 HEWHY CERTIFY THAT I HAVE P7EPARED THIS APPLICAMN AND THAT THE WORK WILL BE DONE IN A CORDANCE 1MTH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> Y <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTI RES THE£OLLOLMNG:-I CERTIFY THAT IN THE PERFORMANCE OF THE W'Ogl T-0R ANKH <br /> THIS PERMIT 18 ISSUED.I SHALL HOT EMPLOY PERSONS SUBJECT TO WORIUNAN'S COMPENSATION LAW I OF CALIFORNIA,' CONTRACTOR B HIRING OR SU"ONI RACTMG SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TWO PERMIT IB 1 SVED.I SHALL EMPLOY PERSONS BURJECT TO WOPMMAN'S COMPENSATION LAWS OF <br /> C A.' THE APPLICA UST CALL 24 NDURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS A 120/14SSa42S. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Blpned X� '�-Title Date ' <br /> ' PLOT MN IOraw to Sada)Sada r <br /> I, NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4, LOCATRON OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,ORMRG DIMENSIONS AND NORTH DIRECTION. - 1 WANSION OF SEWAGE DISPOlAL Symms. - <br /> 3. DIMENBIO"ED OU LWF.S AND LOCATION OF ALL EXISTING AND PROPOSED j S. LOCATION OF WIELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fr: <br /> 8TRUCTlRR1A.INCLUDING COVERED AREAS SVC"AS PATROB,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 1 - DEPARTMENT USE ONLY - <br /> ApplFcdlon Accepted BY ! - Date /O Area Db <br /> Grein Irhpeetlen BF Date - PL p lne4eatlon rBy Data <br /> Oe.tn�atkn IMp-00.BYA' 0 dip Dale <br /> r <br /> CemmenfY. � y <br /> ACCOUNTING ONLY: -AID/ - -- FACT11 <br /> PE CODES FEE INFO AMOUNT REMITTED i CHECKA/CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> Ser jr <br /> Pub Heafth Serv.-Enviro.173(1/97) <br />