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P. 3 <br /> 1 ',--12-1997 9:04AM FROM:,,,, <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> (; ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 55202 <br /> (209)46&3420 <br /> NIOM IIEFURDA9lE PERMIT EXPIRES-1 YEAR FROM DATE ISSUED <br /> ICIPBpMt*In T►$Oabl <br /> APPLICATION IS HERE BY MADE TO THE SAM JOAOUW COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WORK DESCPSBED.THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAM <br /> JOAQUIN COUNDEVELOPMENT TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION <br /> TY <br /> /4'' � <br /> Joe AOORESMOR APM/ �(•,L..� v. � �pl ASN •. _ _CITY PARCEL SQElAPMI�` <br /> OWNER•*MwMi a_,r f n1�1IAi�hioDREes ►• �� '� <br /> CONTRACTOR +� �.. +`-� ✓ AODIIE, 01 �i? ,;t 14,7 h:'i r uaI �i:_;da'!�aHOME 01"11'6 � IBJ le <br /> SUB CONTRACTOR AB LIC7 PHONE <br /> TYPE of WEUAVMPs ❑ NEW wfu ❑ REPLACEMENT WELL © MONITORING WELL/ D OTHER <br /> ❑ INSTALLATION Q WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑M.❑RNP.N H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL C <br /> RYPE OF PUMPI <br /> ❑ OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ s011 601*NO / <br /> �DESTRRPCTIOM: <br /> INTENDED, f TYVE O WELL f T IFiCA 10 A <br /> ❑ INDUSTRIAL, ❑OPEN BOTTOM VIA.OF WELL EXCAVATION VIA,OF CONDUCTOR CASINO O <br /> ❑ OOMESTIWPWVATE ©GRAVEL PACK/912E TYPE OF CASINGISTEEI/PVC DIA.OF WELL CASINO D <br /> ❑ PVSLIC/MUNKMAL ❑DRIVEN DEPTH OF GROUT SEAL SPECVICATION ✓! <br /> [3 , ATIOWAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F <br /> ❑ MONITORING ,/ GRow SEAL PUMPED:E3 Y- 11N. CONCRETE PEOE9TAL 9Y DI*LLER:❑Yr ❑N. S <br /> APFR IX.00.W ,Q-1?�- i.c'� LOMINO CHESTER BOXIOTOVE Pie S <br /> PROPOSW CONSTRMTION/DIILUM METHOD: MW ROTARY MR ROTARY AUGER CABLE OTHER <br /> 1 WItEBY CVtrWY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WOW WPM tE DONE IN ACCORDANCE WTrH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS Of THE SAN JOAOUM COUNTY. HOME OWNER OR LICENSED AOENT't SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 19(*SUED.i SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'(COMPGII*ATON LAWS OF MFPOFMA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTW EI <br /> THE FOLLOWING: '1 CLARIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PWINUT 19 ISSUED.i SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of <br /> CALIFORNIA(..* THE A►PJC MT MUST CALL 24 HOURS IN ADVANCE FOR ALL RIOMID IRI*PWTNONS AT("IR 400}425. COMPLETE DRAWING AT LOWER AREA)PROVIDED. <br /> Slolyd%�\ -� � '[iC _ TNN (.3`�.�-'LC�-7.1� .�•/i'- O.t. /I-_.` {rl <br /> PIAT PIAN Mvew N$..l.)5..1. •is J <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE OISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.GtVINO OIMENSIONS AND NORTH DIRECTION. EXPANYION OF SEWAGE DISPOSAL SYSTEMS, <br /> 3. DIMENSIONED OUTLINES AND LOCAT►DN OF ALL EXISTING AND PROPOSED S. LOCATION Of WELLS WTTMN RADIUS OF ONE MUNDPEO FIFTY FT, <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS„DRIVEWAYS.AND WALKS. ON THE PROPER"OR ADJOINING PROPERTY. <br /> :.....y.....1.. • ..;. ...:.....•:.. ..p... ...y... <br /> • • , <br /> .......•..-.........�......t..�..;.......'.. ..:.. .........i.......i.....4.... .. ...}.... ...y......:......•4......: ...9.....: <br /> . _ i <br /> : <br /> baARTMiVT USE ONLY <br /> AFFS..tNR Aeo ted BY <br /> Ofau brPAIN/+By bat. Puns ttn...tl.n By ON. <br /> Co--HO <br /> ACeO1MRN0 ONLY: I MDI FAC! <br /> K COOTS PER two AMOUNT RtMITTED C ASH REOOVtb tY bATE P ORMIT/SSPMCE REQUEST MuMam INVOICE <br /> Pub.Health Serv.-Erivim.173(1 AM <br />