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APPLICATION FOR INELLIPUMP PERMITS <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P'O' BOX 988, 304 EAST WEBER AVENUES <br /> TOCKTON, CA 95201388 <br /> (209) 468.3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WITH SAN <br /> (Complete In TrIplIl:Atd <br /> JOB ADDQUIN COUNTY DEVELOP/MENTI TRLL,CHAPTEfl 8-111$,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORE89Oq APNF lir ./ CITY <br /> , <br /> / <br /> OWNER'S NAME '(f �� ��PARCEL SIZE/APN! <br /> CONTRACTOR_i'Pq �• _ ��[[[��� ADDRESS ^ aQ�n <br /> 176/ >C ,tTWI'A qCY 47. PHONEF <br /> ADDRESS — Z09 <br /> SUB CONTRACTOR ADDRESS <br /> 13 gS Wt lK;/ PHONE A-i) -ZO,2D <br /> "L <br /> ADDRESS -3 <br /> SY��1N N. <br /> L1C8 Sf 2 -"' 209 <br /> TYPE OF WELl1PI1MP: 11 NEW WELL PHONE I�[,5��'j/z <br /> ❑ REPLACEMENT WELL �1 <br /> ❑ INSTALLATION � MONITORING WE ❑ OTHER .n <br /> ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT RE AIR <br /> DYPE OF PUMpI ❑New❑Repel, H.P. ❑ VAPOR EXTRACTION WELL/ <br /> DEPTH PUMP SET FT. i <br /> ❑ <br /> OUT-OF-SERVICE WELL �lFIRST WATER LEVEL <br /> �— 0 <br /> ❑DESTRUCTION: GEOPHYSICAL WELL,I N SOIL BORING ( G / (T��• <br /> �e B <br /> INTENpFD USE TYPE OF WELL <br /> ❑ INDUSTRIALCONSTRUCTION SpECIFICATIONt <br /> ❑GRAN BOTTOM DIA.OF WELL EXCAVATION_ <br /> DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE A V <br /> 11 _ TYPE OF CASING/STEE DIA.OF CONDUCTOR CASINO_— D`D`91 <br /> R1BHD/MUNICIPAL ❑DRIVEN ! Dlq.OF WELL CASINO <br /> ❑ IRRIGATION/AO DEPTH OF GROUT SEAL / _ ��_ <br /> ❑OTHER GROUT SEAL INSTALLED NY-.Q C U SPECIFICATION <br /> ❑ MONITORING R <br /> PUMPED: ❑ya ❑No GROUT BRAND NAME-- £� <br /> APPROX.DEPTH GROUT SEAL PCONCRETE PEDESTAL By DRILLER: ya O <br /> LOCKING CHESTER BOX/STOVE RPE ON. <br /> PROPOSED CONSTRUCTIONIdtlWNG METHOD: MUD ROTARY <br /> AIR ROTARY AUGER 9 <br /> CABLE OTHER <br /> I HEREBY ONS FV THAT I HAVE LAIN CoEO THIS APPLICATION AND THAT TME WOIK WILL BE DONE IN AC1 1 1 FILCI WITH SAN JOAOUIN COUNTY ORpINANCEB,STATE LAWS,AND RULES AN <br /> REGULATIONS OF THE SAN JOAQUIN CUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: It CERTIFY THAT IN THE PERFORMANCE OF THE WON(FOR WHIN , <br /> THIS FERMI IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' COWRACTOR'S HIRING OF'SUB-CONTRACTING SIGNATURE CERTIRE <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,18HALL EMPLOY PERSONS SUBJECT TO WORO AN'S COMPENSATION LAWS O <br /> CALIFORNIA./ TAT CALLyA HDUµ11y.pVANCE F011 ALL REQUIRED INSPECTIONS ATTSISOBI IIBJE=S. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> elEn.a% 4 .2z I J/A��—Fitt.� it/ ✓' f q <br /> Dot -!S <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING PLOT TH NpgOpEgry el Bub 'to t7�/ <br /> Z. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND Wg . EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> U(g <br /> S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY <br /> APytllen MooRw IS <br /> DAIe <br /> GrON len BY Dote -p = By <br /> Ma �� <br /> Dela <br /> Droll <br /> lruen lapsetlen BY <br /> Commenb: .Q <br /> DNa <br /> U// <br /> ACCOUNTING ONLY: AIDA <br /> FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECOVE BY DATE <br /> P9IMITISFRNCE REQUEST HUMBER INVOICE <br />