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� ( <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 2 Q v <br /> (209)468-3420 7 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complet#M TTIpkat#) <br /> APPLICATION 18"ERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.T"IS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AOORE98/OR APN/}"� r CITY �PARCEL SIZE/APNf �//� Q <br /> OWNER'B NAME / U6� /�/� ADDRESS �/ r PHONE f — 9, <br /> CONTRACTOR AOD11E8B / f' ' PHONE f <br /> eve CONTRACTOR ADDRESS /I - UCf PHONE f ��z-S <br /> TYPE OF WELLIPUMP; M": <br /> WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> 9 AUJLT10N ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f ✓ <br /> ✓'V�, d New❑Rap* H.P. DEPTH PUMP SET /40T. FIRST WATER LEVEL O <br /> RYPE OF PUMP) / v <br /> ❑ OVT-0FSERVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS u A <br /> ❑ 1NWBTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> /MESTICIPi#VATE rcpIL <br /> RAVEL PACK/91ZE TYPE OF CASINO/BTEEUPVC DIA.OF WELL CASINO_ D <br /> ❑ PUSIXIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION /}-C�,�L�q/� a <br /> ❑ IRRIOATION/Ae ❑OTHER GROUT SEAL INSTALLED <br /> ,..{BYY� GROUT BRAND NAME rTSL-✓!/'S�Z���y- E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑No CONCRETE PEDESTAL BY DRILLER:❑Yse,p Ike S <br /> APPROX.DEPTHLOCKING HESTER BOX/BTOVE PIPE �/v S <br /> PROPOSED CONSTRUCTION/D18LUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIE9 THE FOLLOWING:1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,1914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'#COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR 91.1"ONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING' ' C IFY AT IN PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'#COMPENSATION LAWS OF <br /> CALIFORNIA.' HE MUS UR#IN ADVANCE I"ALL REQUIRED INSPEC�TIONN8 AT 120#1###-04". COMPLETE DRAWING AT LOWER AREA PROVIO D. <br /> Owed X Title �(�-X � � Date <br /> PLOT PLAN(Drew to Seale)Bode '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,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWAOE DISPOSAL SYSTEMS. <br /> S. DIMENSIONED OUTLINES 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, /D 3- ON THE PROPERTY OR ADJOINING PROPERTY. <br /> -11/% <br /> '9'71 <br /> AUG 2 <br /> UF%LIG <br /> ��. MENTAL HFALTF,i q�l4lSld a3•: <br /> /� r <br /> t t <br /> ... ....:...: _ . <br /> DEPARTMENT USE ONLY <br /> Appiloetlen Aeeapled 9Y �� Dole 3 11tee <br /> Omit Inepeetlen BY , Date Pvnp Inepeetlen BY '''Date <br /> D-wictlen Inepeetlon B 7-,, r,, /� 1 Dote <br /> Cemmenle:�y�� V /L"` �" �v <br /> ACCOUNTING ONLY: MD# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED BY DATE PEPIMIT/SERVICE;mc NUMBER INVOICE <br /> 2A 1A A 0 V �— <br /> Sz' o oA <br /> Pub Health Serv.-Enviro.173(1/97) <br />