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Cj At <br /> ^ ? <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC.HEALTH SERVICES` T_ <br /> ENVIRONMENTAL HEALTH DIVISION :. r <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 4ss-U2o � 64 .)8 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUfl1 , <br /> (Complete IS TrlpRnt.l <br /> APPLICATION IS HFRE SY MADE TO THE SAN JOAOIRN COUNTY FOR A PERMIT TO CONSTRUCT AMUMR INSTALL THE WORK DESCRIBED-TIttS,APPLICATION IB MADE INCOMPLIANCE WFTH SAN <br /> JOAOUIN COUNTY DEVELOPMENT T CHAPTER 9-1115-3 AID THE STANDARDS OF SAN JOAaUM COUNTYPUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRES9AaR APNP 1 9 [..N " 1�G{♦ PARCEL SKEIAPMv L5F L�}{"� 4- <br /> OWNER'S NAME Wim ir' �'j A xX4h d�r� TIr%Oet .-_AOORE9s P Al C� Jojo, CA 950 b PHONE,' 0 'V 53 <br />. LtlNTRACTOR� f f (./�! f _ 'ADDRESS Pr1. -. '.' %t Llcr rLc'�1 .. PHONED j� <br /> SIiS CONTRACTOR rlx- <br /> AOMSO LIC/ PHONE P <br /> ^I <br /> TYPE OF WELLIWMPK ❑ NEW WELL ❑ REPLACEMENT WELL MONTORING WELL I ❑ OTHER - - <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRO89CONNECT REPAIR. VAPOR EXTRACTION WELL f J <br /> ©N.w .©Reo.lr H.P. DEPTH PUMP SET FttiST WATER,LEVEL O <br /> STYPE OF PUMP) I] OU1r-0F-SERVICE WELL - ❑ GEOPHYSICAL WELLP - I� SOIL BORING <br /> ©DESTRUCTION: V <br /> INTENDED USE TYPE OF-YYEI! CONSTRUCTION SPECIFICATIONS �L _ A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION n�� i A DIA.OF CONDUCTOR CASINO N A' P <br /> ❑ ooME9TICRRVATF ❑GPIAVEL PApKBr[E. TYPE OF CASMGISTEEI-MM ` \1 G. DIA.OF WELL CASINO{ A I,L+ D <br /> ❑ PUSL WUN ICIPAL ❑DRIVEN DEPTH OF GROUT MAL_ N S Q— ft - SPECIFICATION ���7 P Y C I C.� �0)R <br /> © IRMOATIONIAG '❑OTHER' w GROUT SEAL eNSTALIED BY T r 11 1 ILL _ OROU'SPAM NAME N e rwe P � E <br /> NT <br />! 0 MOrORING ' /n'� GROUT SEAL PUMPED: MY. [IN. �; CONCIPIM PEDE6T]A�L BY DRILLER:0 Yr ON. - S <br /> APPROX-DEPT14 1z S 55, 3 •'}W U V f LOCKINO CH✓✓ENTER BOXMO�PIPE ,E f` 5 Yt re C t <br /> PROPDSEO D CONSTRUCTMNaMUn METHOD* MUD ROTARY AIR ROTARY ^ AUGER CABLE OTHER ; <br /> I HMIFY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAKKRN COUNTY OIOMANCES.STATE LAWS.AND RULES AND <br /> FtEOUTATIONO OF THE SAN JOAQUM COUNTY. HOME OWNER OR LICENSED AGENT'S&VNATURE CERTIFIES THE FOLLOWING:I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH <br /> THIS PERMR IS ISSUED.I SHALL NOT EMPLOY NO SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HINPIO OR BUB•CONTRACTRM 91GNATURE'CfRTIFIT9 <br /> THE FOLLOWING: '1 CERTIFY THAT IN ANCE OF THE WORK FOR WHICH THIS PERMIT 19 IBM".I SHALL EMPLOY PERSONS SUBJECT TO WORK MAN7 COMPENSATION LAWS OF <br /> CAI,IFORMA T APPLICANT T C M HOURS IM ADVANCE FOR ALL REOUIR� SPICTIONS AT 12MI SN-*42*. COMPLETE DRAWING AT LOWER AREA PRDVIDED. _ <br /> If two Dote <br /> J. <br /> . 'RIOT RAN Mrow to .1 Sa.y 'is . <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPER"- a, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR RDIV9ED . <br /> 2. OtTUNE OF THE PROPERTY.GIVING DWENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISrfW ANO Pn*m ED S. LOCATION OF WELLS W1TIm1 RADWS OF ONE HUMOM FIFTY FT. <br /> STRUCTLfMk O CLVMNG COVERED MEAS SUCH AS PATIOS,DRYEWAYS,ANO WALKS. ON THE FIDPFRTY OR ADJOPM111 PROPORY. <br /> S L ..� . :.M I .P. . k.�.�..,� H: I~:D ..;........ .>.... <br /> j <br /> _... <br /> - � OE►ANTIMEIT USE trent <br /> Aoplk.tl.n A...Pled BY rI <br /> "",A"""606-ST J D+f+f ISO Irso 11 n BY coteO.�lrtitien IMP.e! Y _ Do7e <br /> Cwnrnenl.• �� � �C " <br /> f <br /> ACCOUNTING ONLY: AIO/ FACE l! <br /> PE CODES FEE INFO AMOUNT TIEAM"To CHECK/ICASH REC ■Y DATE PORSThERVICE REQUEST NUMBER INVOICE - <br /> r <br /> :� -o 00 3 0 1 <br />