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APPLICATION FOR WELLIPUM 3 PERMIT <br /> SxN JOA(lUIN COUNTY PUBLIC HE LTH S>ERVICEb:---,' I.�, <br /> ENVIRONMENTAL HEALTH 0 VISION R E�'E <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST.. S OCKTON, CA 96201.388 w,��3��- <br /> {209) 468-3420 MNf 1 0 2n <br /> XON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC7.'D <br /> Mompl.to in Tripl'lailtel ENVIR�jl ;1,-:. <br /> PPLCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR IN THE WORK DESCRIBED•THIS AFFUCATIO IS ADE WIIAP()AmC %TYII JBA 4 <br /> OAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> O$ADDRESSOR APNI /013 r [1A,4-- CITY roc �Q �JPARCEL SZFJAPN# 2 <br /> .'.B DD — _ S/t�lr�`-'�I3 JQ• C#�L <br /> PHONE* <br /> ;WNER'S NAMEADDRES <br /> J!;;7207 <br /> V, �O[CLCx PHONE IS �I l <br /> V <br /> ADDRESS It <br /> ONTRACTOR lKI C/ PHONE x L <br /> CONTRACTOR HCr�4 S DR,/ ,4,/!//G Cc Ul/0 ADDRESS- <br /> -"aE OF WELLJPUMP- ❑ NEW WELL. ❑ REPLACEMENT WELL MONITORING WELL fflam- ❑ OTHER <br /> D INSTALLATION ❑ WELL SYSTEM REPAIR gcROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J <br /> ❑Naw Cl Rapalr N.P. DEPTH PUMP SET FT.-- t�FIRST WATER LEVEL O <br /> ''PE OF PUMP! SOIL BORING• 9 <br /> ❑ OUT-0FSERVICE WELL. Q GEOPHYSLCAL WELL X / 1 <br /> DESTRUCTION: <br /> `ENDED USE TYPE DF WELL CONSTRUCTION SPECIFICATIONS '4 O <br /> WOES USE <br /> ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D W i <br /> OOMESTICIPRIVATE ❑GRAVEL PACKlSiZE TYPE OF CASINGlSTEEL7PVC DIA.OF WELL CASING <br /> Z" <br /> PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL sPECIFLCATION R <br /> $MGATIONIAG ❑OTHER GROUT SEAL INSTALLED By. <br /> L L GROUT BRAND NAME < E <br /> {MONITORING �, { GROUT SEAL PUMPEfl: !��'w ❑ CONCRETE PEDESTAL BY DWLLER: w ON. S ^ <br /> -MOX.DEPTH ir!i!ING <br /> 7 T � LOCKING CHESTER BO STOVE PIPE <br /> �CPOSED CONSTRUCTLON METHOD: MUO TARP AIR ROTARY A GFA CARL£ V/ OTHER <br /> 4EpEBY CERTIFY THAT I HAVE PREPARED THIS APPUCATON AND THAT THE WORK WILL BE DONE IN AcccRDANCEWrrH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES ANDN <br /> 13ULAT10NS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCFNSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH`i <br /> -iS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WOROAAN'S COMPENSATION LAWS OF CALIFORNIA.' COHTRAGTOR'9 HIRING OR SUB-CONTf1AL'TING SIGNATURE CERTIFIES <br /> -+E FOLLOWING: 'I CFFrTFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, LO <br /> I SHALL EMPLOY PERSONS SUBJECT TO WOR"&M-8 COMPENSATION LAWS OF"`1133 <br /> s.tJFORNI0.' CANT MUST CALL M HDUR6 IN ADVANCE FOR ALL REQUIRED I TLOMS AT 1 1 71. COMPLETE DRAVANG AT LOWER AREA PROVIDED. <br /> �'�ISS <br /> ywa X Tltla <br /> PLo lor.w to 5oela}st:de •to <br /> NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ; <br /> OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL 6YbTEM6. j <br /> DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPEKrY OR ADJOINING PROPERTY. + <br /> .. ......_... .. .. .. .. .. .. .. .. .. <br /> .. .'........ ...:........._,..............:... .....................-.;.....:....................,............ ........_....,..........................;. ....... .... . <br /> I <br /> I <br /> -. .....,. .. :.............f.... ..... _......- .. 1 - ...... ....... .. ....... <br /> ... .-..�_ .....1 <br /> -.. <br /> o y <br /> A. <br /> ...:: ..... ` :::: ..:. <br /> .. ...... <br /> i DEPARTMENT USE ONLY - <br /> ­d= mt Accepted BY Once <br /> ,out lmpaudo BY Date Pump lnapocu*n By Dale <br /> .,meq=hm Inepeadon BY Du <br /> .atnnenn• <br /> Ila-1, LC•Z -3 <br /> ACCOUNTING ONLY- AID# FAC# <br /> FE CODES FEE INFO AMOUNT RRATTEC CHECK#ICASI RECOPW BY -�9 PERMITISERVICE REGUEST NUMBER INVOICE <br /> s/mAk swe 0S9 <br /> j <br />