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APPLICATION FOR WELLIPUMP PERMIT <br /> �;AN JOAQUIN COUNTY PUBLIC HEALTH SERV,_, <br /> ENVIRONMENTAL HEALTH DIVISION �I <br /> 0 BOX 388,445 N.SAN JOAQUIN ST,STOCKTON,CA 95291.388 <br /> (209)488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompIN{in Trlpl'i1:ElE1 <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCEWITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH bf ASION. <br /> JOB ADORESSIOR APNI / A/ $]T?I�Z�j" CITYPARCEL 812E/APN/ <br /> OWNER'S NAME [ 1�1- - y.,_.�.1 ADDRESS�p,J� U-8JE?4* -,0r.�O"W- OS PHONE APS- <br /> CONTRACTOR LtL TTA'L{w[ -/t..L/+_f.aZ ADDRESS Ig03 W.M%J"(^N *4 LIC/ PHONE{ ZI T7 <br /> /'� �� SR'bCJ�T►!J G+4 620'7 <br /> SUB COHTRACTOR�jEZAI. o-n�.,. ADDRESS hggm= Crjfly7 LICI&DL72D PHONE'22,7 <br /> TYPE OF WELLMUMP, ❑NEW WELL ❑REPLACEMENT WELL ❑MOMTORINO WELLS ❑OTHER <br /> ❑INSTALLATION 13T <br /> WELL SYSEM REPAIR ❑CRROSB-CONNECT REPAIR ❑VAPOR EXTRACTION WELL{ <br /> (TYPE OF PIMP <br /> Q New LJ Rep.1, H.P. DEPT"PUMP SET FT. FIRST WATER LEVEL O <br /> I-� 11 OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL P ❑ SOIL BORING g <br /> TLl DESTRUCTION: ^'3 1���� <br /> INTENDED USE TYPE Of WELL CON{TRUCTION SPECIFICATIONS <br /> p A <br /> 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF IAIELL EXCAVATION // " A.OF CONDUCTOR CASINO 0 <br /> ❑DOMESTICIPRIVATE ❑GRAVEL PACKiMzt TYPE OF CASINGISTEEUPVC__R/(— DfA.OF WELL CASINO Z'r 0 <br /> ❑PUSUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ _... SPECIFICA71ON R <br /> E[❑IRRIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> yy <br /> SRMOMTORINOIV Y_l.•T� GROUT SEALPUMP:D:❑Vr ❑No CONCRETEPEDESTALNYDRg1.ER:❑ SAPPROX. yw ON* <br /> APPROX.DEPTH _ LOCKING CHESTER BOXIBTOVE RPE J: <br /> PROPOSED CON"UCTIONIDRWNO METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORN WILL BE GONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY,HOME OMEN OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIN PERMTT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOMR&'CONTRACTOR'S HIRINO OR SUBLONTRACTINO SIGNATURE CERTIFIES <br /> TNF POLLOWIN02 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF <br /> CALIFORNIA.' THE <br /> !grANT MWT CA II NOUN IN ADVANCE FOR ALL BEWIMED INSPECTIONS At I21M1 ARgJlSt,COMPLETE DRAWING AT LOWER AREA PROVIDED, <br /> {kt.t/X THD. <br /> PLOT RAN 0-1.S.W.) <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 SYSTEMe. <br /> 3.DIMENSIONED OUTLINED AND LOCATION OF ALL EXISTING AND PROPOSED F.LOCATION OF WELLS WITHIN RADRIB OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAtXe, ON THE PROPERTY OR ADJOINING PRoPERTy, <br /> I <br /> DEPARTMENT USE ONLY J q <br /> Applk.,bn Rea pt.E B <br /> G'.ut t.p-11-BY 't I_S f•"y"/\'-' Oa.5 3�9 ptmp Rn.pperfon By oaa <br /> De.irtxtlen Impc,lon By Do. <br /> c.mtpem.: [) L — LSh4713 t.. r3 F <br /> ACCOUNTING ONLY: Alp( FAC! <br /> ►E CODES FEE INFO AMOUNT REMITTED CRECKAICMN RECEIVED BY DATE PUTARTISERVICE REQUEST NUMBER INVOICE <br />