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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER .S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 9MII1� Atjjf <br /> (2091 469-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM OATS NtSBEOZ 7 PI? 3: 17 <br /> (Complete in Triplicate) <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WORK DEBCNBED.THIS APPLICATION IS MADE IN COMPLIANCE WrrH SAI <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11115.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBl1C HEALTH SERVICES,ENVIIKINMENTAL HEALTH DMBION. <br /> JOB ADDRESSMR AMI Ul LJ1c'OU^ �ry.^ CITY LaI'-1 PARCEL SUMAP NO.1 <br /> OWNER'S NAME SIv II u,I r?/.LL:�{S LV,MCc_IADDRESS I--l.,. CJx 4�FG'il L Lcyl_t�::(• CI''i PHONE F1S7u)L�S"LIEF: <br /> CONTRACTOR (X (�LL. `�ST> Ifowc K+E I�[^ir•"�L�.LLen# > PHOISIA57D/jL3-aCG <br /> SUBCONTRACTOR ' Af9 4Vt .'4 1.«I AOIJREaBi1J�v .�}.A L[.+_ N.W.A4tIC1 PHONE ell <br /> TYPE OF WELLPPIIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITOmw WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS{ONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> ❑N.❑R.O.b H.P. DEPTH RUMP SET FT. FIRST WATER LEVEL C <br /> TYPE OF PUMP <br /> ❑ OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL I t I SOIL SORINO <br /> �1 <br /> DESTRUCTION: P".F� :i•'np^� l.Ji i <br /> 1 <br /> INTENDED USE TYPE OF Well CONSTRUCTION SPECIFICATIONS A <br /> ❑ INOUSTMAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO C <br /> ❑ DOMEBTIC/PRIVATE ❑GRAVEL PACKISI2E TYPE OF CASINGISTEEVPVC DIA.OF WELL CASING _ <br /> ❑ PIBLICDAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION P <br /> ❑ IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PIMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑NP <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PPE <br /> PROPOSED CONSTRUCTIONIDIOWNG METHOD: MUD ROTARY AIR ROTARY AVGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AN <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 WHIC <br /> THIS PERMIT IS ISSUED,I&HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBLONTMCTINO SIGNATURE CERTIRF <br /> THE FOLLOWING: -A CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 16 ISSUED.I SHALL EMPLOY PERSON&SUSJECT TO WOMONAN'S COMPENSATION LAWS C <br /> CALIFORNIA.- T�(/ ANT MOeTGALL 24 HOUMS IN ADVANCE FOR ALL REQUIRED INSPlCT10NS AT 120514Y-1425. COMPETE DRAWING AT LOWER AREA PROVIDED. <br /> 81,w X .(—'' �— Till. <br /> PLOT PLAN IQ—to 50.1.1 Sa.M 'to l <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 SYSTEMS. <br /> 3. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. 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 ADJOINING PROPERTY_ <br /> DEPARTMENT USE ONLY <br /> APPnslmn Accepmtl BY <br /> I <br /> Gram L p. fl.n BY O.t. R. 1— . Ot BY Da. <br /> OrvuOtlen Impaetlen BY D.,. <br /> Cemmstts: <br /> ACCOUNTING ONLY: AIDS FACT <br /> PE CODES FEE INFO AMOUNT REMITTED NEC (CASH RECEIVED BY DATE P TIeNMCE REQUEST NUMBER INVOICE <br />