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--- ?PLICATION FOR WELUPUMP PERMITg.. <br /> SAN AOUIN COUNTY PUBLIC HEALTH SEA ;ES <br /> ENVIRONMENTAL HEALTH DIVISION ORIGINAL <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICempIBN In TrlpRets) <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER <br /> 9-1119,3 I <br /> ANDSTANDARDS THE STANDADS Of SAN JOAQUIN COUNTYT/ HE <br /> PUBLIC HM <br /> HEALTH SERVICES, ENVIRONMENTAL HEALTH DBION. <br /> JOB ADDRESSOR APN# r D LI W is I C7'I 41 7 o Y CHY �s Q (. A �/ () f\) PARCEL SIZEIAM0 <br /> ' 11 � p 1l C <br /> OWNER'S NAME Up. "F-II1 � 1 Q (IIcAucC1`(I.(L CQ . Q NflM 1I;Ai ADDRESS P. \� . p4' 11- 4' b 115 iat K'1 O n95LG PHONE t &A> YJ*& 9 3 <br /> commemit 'q,31 ; 4AAW) L3 Po Cgv ; tnnMfNTA � T �nLJ1oDl�eeyyn `J NI K)IlsO n [%)4 HDt -fi Z2 PNONEt 201-. 7- /tmlp <br /> OUR CONTRACTOR p ADDRESS LICE PHONE #t <br /> T"" OFWELU14 4 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLS SPSIQC. r <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR VAPOR EXTRACTION WELL It (51 J <br /> ❑ Nen ❑ nmAv H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL 'i I S O <br /> (TYPE OF PUMP) <br /> ❑ OVTCFSERVICE WELL ❑ GEOPHYSICAL WELL t ❑ BOIL BORING B <br /> ❑ DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑ OPEN BOTTOM ne� DIA. OF WELL EXCAVATION 9, � iAc14 DIA. OF CONDUCTOR CASING N! R G <br /> El DOMESTICI%DVATE GRAVEL PACK/SIZE JSAAtf) TYPE OF CASINO/BTEEIT�V{C` 1� DIA. OF WELL CASINO 1 L O <br /> ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF BMW SEAL H'UDCO [' 1 � ` �onT SPECIFICATION _ S <br /> ❑ IRMOATONIAG ❑ OTHER BMW REAL INSTALLED BY �E M I BMW BRAND NAME : E <br /> ❑ MONITORING 7 C / BMW REAL PUMPEOI Jay" ❑ Ne CONCRETE PEDESTAL BY DRILLER: Yr OND S <br /> APPROX. DEPTH I "OT r(� 0 T LOCKING CHESTER BOX/STOVE PIPE S <br /> PLIOPOSM CONOMM"OWMMWMO METHOD: MUD ROTARY AIR ROTARY AMER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPIICATON AND THAT THE WOPL WILL BE DONE IN ACCORDANCE WITH SAN JOADUIN COUNTY ORDINANCES. STATE LAWS, AND I1UlE8 AND <br /> REGULATIONS OF THE SAN MADUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CEWIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> TMg MMM IS tSSUED, 1 RI4ALL NOT EMPLOY PERSON@ OUBJECT TO WORKMAN'S COMPENSATION LAWN OF CAUFOMA: COWRACTOR'B.NINNO OR M"OWMCTIM MONATUIIE CERTIHES <br /> THE FOLLOWING: • 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TOM PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WOMKMM'S COMPFNBAUON LAWS OF <br /> CAUFORNA.• _jNE APPLICANT MOST CALL NO IN ADVANCE FOR ALL MOUMM INBFFCTIONS AT IXOBl4gi4", COMPLETE DRAWING AT LOWER MEA PROVIDED, <br /> mBneax /lmu n Cl ' <br /> This ti 1n � STA /=Frn / , G� � D.1. jQ — jp <I8 <br /> PLOT PLAN Mrnv Costal %ala ' <br /> / . NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISMSAL SYSTEM OR PROPOSED <br /> Z. OUTLINE OF THE PROPERTY. OIVMO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> G. DIMENSIONED OUTLMF.B AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN MMS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES, INCLUDING COVERED AREAS OUCH AS PATIOS, D1VEWAY8, AND WALX8, ON THE PROFettrY oR Av"nowG PROPERTY. <br /> DEPARTMENT USE ONLY <br /> APPlImtIvn Aeeepled BY Dale D v I- Arm 0� <br /> OraW Imvealbn BY DatePump Inapecllan BY Dale <br /> DmIrmilan Im ealNn BY Dote <br /> Dammar,ts: <br /> ACCOUNTING ONLY: AID# FACE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CABH RECEIVED BY DATE PEI0.UTMERVICE REQUEST NUMBER INVOICE <br /> Pub Health Saw. - Enviro. 173 (1/97) <br />