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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. C.A. 35201388 <br /> (209) 068 3420 <br />. NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (compl6ts In TrIpPleatm) <br /> APPLICATION AS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMrr TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED THIS APPLICATION 18 MADE IN COMPLIANCE WITH <br /> JOAQUIN COUNTY DEVELOPMENT TITLE CHA�PTTEERR 9 1�1�1 S 3�AND THE/S,�'TTAANDARDS OF SAN JOAQUIN COU'NT'Y PUBLIC-HEEAALLTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> JOB ADDRESSIOR A/PNjp_'/��,Ia� /'Y��/�_�j'j�L/Cr� !G//'� �_crinY^ �f/'•±+l�T C/-�/� �J PAjRCEL BIxElAPT1E _ <br /> LA,V'7 1!R 6 NAME Ll/y/�,C�'!Arw W - f'�tC/cif/ i�. �'+� ADDRESS,O''f O 6O L �W'^e,47% 0O� r�"(' , ��PHONE Ia ���-/� <br /> CONTRACTOR y�lyG/7 {JV'(//��/t.��G'�!✓e ADDRf86- / fJ��1r,���YJ7�/� ,, _�yL�IC/ /%� PH(O/kEl� <br /> SUBCONTRACTOR_ pO!/[/L�rT/� �/YL7 ADDRE86PU r-O)( 3_ 6 /U� L/rs//7UCI`�� r I�P1IONE �J <br /> TYPE OF WEIL"MP• "I WELL ❑ REPLACEMENT WELL MONITORING WELL& ❑ OTNER <br /> STALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL If <br /> ❑Now❑Rewlr H P DEPTH PUMP SFT FT FIRST WATER LEVEL <br /> rtYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ OEOPHYSICAL WEL1 f ❑ BOIL BORING <br /> ❑DESTRUCTION <br /> INTENDED USE TYPE OF WELL CONSTRUCTION 8PEC1FICA?IONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA OF WELL EXCAVATION t�_/- DIA OF CONDUCTOR CASING <br /> ❑ OOMESTICIPRLVATE ,❑ RAVEL PACKISIZE TYPE OF CASINGIBTEELn-VC PICG DIA.OF WELL CASING /✓ __ <br /> ❑ PUBUC/MUN)CEPAL ��DRIVEN DEPTH OF GROUT SEAL 7 SPECIFICATION ArC . ✓ f <br /> I� D E3❑�IRA)GATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> YJ f yL'I"T �jV1E f <br /> MONITORING f GROUT SEAL PUMPED Yr ❑Ne CONCRETE PEDESTAL SY DRILLER❑yet No w <br /> `AP ROX DE71 ®`V LOCKING CHESTER BOXISTOVEIPE�� <br /> PROPOSEb CONSTRUCTIONIDpLLINO METHOD MUD ROTARY AIR ROTARY AUGER L� CABLE OTHER <br /> 1 HF9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULES Ar <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY HOME OWNER OR LICENSED AGENT S 81111"ATURE CERTIFIES THE FOLLOWING '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR Will' <br /> THIS PERMIT 19 ISSUED 1 8HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFI <br /> THE FOLLOWI '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED I SHALL,EMPLOY PERSONS SUBJECT TO WORMAN 8 COMP'ETIBATAON LAWS <br /> CALIFORNIA THE APPLICANT T MgL7M4 IN ANCE�F�JO�R�AALL RR�ETO�IIMR IN MMICG,T�IOJNrSAT 1�2I�/YJAOS-3422 COMPLETE DRAWING AT LOWER AREA PROVIDED <br /> /-/ z57 <br /> �nsd X V�rrTLt.vrT)tlr _a'1 '-Yf --' "r"�� , / Dana� <br /> PLOT PLAN Shaw to Sasiel Soa1s 'to <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 GTYIRNI DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMS <br /> 3 DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTINO 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 PROPERTY OR ADJOIMNG PROPERTY <br /> DEPARTMENT USE ONLY <br /> Aav4"%t Anoeptod By — 7 <br /> Date 5— _SJ Mee <br /> Grout Impaction By Date P=p Inspection By Data <br /> DeatrmtIcn Urpaatko By Data <br /> Comnrontr <br /> ACCOUNTING ONLY AID& FAC/ <br /> PE CODES FEE INFO AMOUNT WMITTED CHECK&ICASH RECEIVED BY DATE ♦"IMITISERVICE REQUEST NUMSER INVOICE <br /> wt O f t;PL—Ol!/S.?— <br />