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'• APPLICATION FOR WELLIPUMP PERMIT <br /> �AN JOAQUIN COUNTY PUBLIC HEALTH SERV <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201386 <br /> 1209) 466.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSORAMO. 'I4,� L1.'•CI'1!].V(!'✓I��a Li Cl-FY GA1 PARCEL SIZE/APN# I��—L2^(2 <br /> OWNER'S NAME UJ:uJ.,h•! IN S AD011E66 °J OZ PHONES /' F <br /> Y PNS 1 a ,S / ill o t701J <br /> CONTRACTOR �-w pr, /JV7l) ADDRESS '/ '?9'77/ Uc1:z&!2 <br /> 24- PONE{ 3"74-26/5 <br /> SUB CONTRACTOR ADDRESS LIC# PRONE <br /> TYPE OF WEUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL f�_ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION <br /> yW�,ELL# J <br /> ❑N.11Recall N.P. DEPTH PUMP SU-17. � FIRST WATER LEVEL �y O <br /> RYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING B <br /> ❑DESTRUCTION: <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION ePECIRCATIONSA <br /> R <br /> ❑ INDUSTRIAL R❑OPEN BOTTOM DIA.OF WELL EXCAVATION {Lc' P DIA.OF CONDUCTOR CASINO 0 <br /> ❑ DOMESTIC/PUVATE Iy GRAVEL PACK/SIZE 2 ( 2_ TYPE OF CASING/STEFL/PVC !'V DIA.OF WELL CASINO 21, D <br /> ❑ MBUC/MUNICIPAL DRIVEN DEPTHOFGROLRSEAL SLIRFA66' SPECIFICATION SL./J yc7 R <br /> p❑l IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY CL$T'•V[)CIO% GROUT BRAND NAME E <br /> ICt MONITORING GROUT SEAL PUMPED: JRY. ❑Ne CONCRETE PEDESTAL BV DRILLER:❑Yr [:]No S <br /> APPROX.DEPTH �� ( LOCKING CHESTER BOX/GTOVE PPE 'X S <br /> PIOMSED CONSTRUCTON/DRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'B HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 CERTIFY THAT IN THP PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- HE A CANTOUIll 24 HOU BIN ADVANCE FOR ALL REOMM INBPECTONS AT 12061 J42S. COMPETE DRAWING AT LOWER AREA PROVIDED. <br /> Slemd% aJY Title J��l!�h74�' DN. <br /> ROT PAN 0.to Scala)Sul. lesh .✓� <br /> 1. NAMES OF STREETIC1411D.NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,DIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> S. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> �az Op Y: ixb aeO II (� <br /> ogm N etD 4J E 'b 11-JI oZ <br /> u p ve`oe CSW _ <br /> L °T <br /> > N F, o <br /> ;I <br /> P o t'A <br /> •` yyn..cee �3°•� <br /> �xo 7 <br /> .o <br /> L <br /> ( <br /> k l <br /> ENT USE ONLY <br /> Application Accepted By Data —�z O Ara. <br /> Glom Impectlen By Data Pump Impeetlen By Data <br /> Dstrmtion Impaction By Data <br /> C.mmap,W <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKOMASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> -Z <br />