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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOADUIN ST., STOCKTON, CA 95201-388 <br /> (209) 488.3420 <br /> NOB-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICGmplfb is Tripliuu) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDX)R INSTALL THE WOW(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COU[N/JAY PUBLIC H1EA1LTH SERVICES.ENVIRONMEMAL HEALTH DIVISION. <br /> JOB AOOREeSOR APNI1'2*2IL' <br /> II ^y 11 CITY J.-&L�L'D Y� PARCEL SIZE/APN/ <br /> OWNER'S NAMEn/ e.VY'Or-% LI.L�.4^ . l /b uWI. S �O, ADDRESS 1 l PHONE <br /> CONTRACTOR—f"r rBL U. L— C-l2Ir?dLr, A' 90, ADDREss � 1`v UC#69r)l39 PHONE <br /> SUSCONTRACTOF�{�r�Ln1 EY^)]IA/IS110T Irv-. ADDPEfi85w~ lO Y'F UC15YL71o6 PHONE <br /> MM T <br /> TYPE OF WELLAIMP'. 09 NEW WELL ❑ REPLACEMENT WELL IG MONITORING WELL I M 8 ❑ OTHER <br /> ® INSTALLATION ❑ WELL SYSTEM REPNR Cl CROSSCONNE <br /> � A <br /> C <br /> �TREPAIR ❑ VAPOR EXTRACTION WELL I <br /> �_ ❑N.01R ., H.P. AA DEPTH RUMP SET M. FT. FIRST WATER LEVEL O <br /> HYPE OF PUMP) _ <br /> ❑ OUT-OFSERVICE WELL ❑ GEOPHYSICAL WELL l ❑ SOIL BORING B <br /> ❑DESTRUCTION: (� <br /> INTENDED USE TYPE OF WE31 CONSTRUCTION SPECIFICATIONS // A <br /> 11 INDUSTRIAL 11AOPEN BOTTOM ..����,, ���� ` � DIA.OF WELL 11) <br /> EXCAVATION DIA.OF CONOUCTOR CASING R O O <br /> 13DOMESTICMRIVATE 11 GRAVEL PACKISIZE � TYPE Of CASINGISrEEI/PVC DIA.OF WELL CASING 11 0 <br /> ❑ PoBLIC/MUNICIPAI. ❑DRIVEN DEPTH OFGHOUTSEM. SPECIFICATION Q 0•o20 SN'R <br /> pl <br /> qJR <br /> NO IRISGATIONIAG ❑OTHER GRouT SEAL.INSTALLED BY be. <br /> lee,- GROUT BRAND NAME E <br /> MONITORING GROUT SEAL PUMPED: ❑V- NO CONCRETE PEDESTAL BY DRILLER:❑Ys ❑NO S (� <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE APE SJ <br /> PROPOSED CONSTRLOTION,DNWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE W7H SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND PLUS ANO h/ <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHIC \ � <br /> THIS PERMIT 19 I"UED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIESL\\\S <br /> THE FOLLO NG: I CERTIFY TNAT INT PERFORMANCE OF THE WOPK FOR WHICH THIS FER.1R 18188UED.1 SHALL FMRpY P£RBONB SUBJECT TO WORKMAN'f COMPEIIBATON UWS OF <br /> CMJFORN NE CANT MWT C 3A HNI IN ADVANCE FON ALL REOUNIFD IN HORS AT 11051 JA2S. CO PIFTE DRAWING aT LOWER APPA P110VIDED. q <br /> sIE1Ne x ml.�e�,Q�F�G Ov 1,5 o.t. � L <br /> PLOT PLAN ID•µto SOalal Sul. my <br /> 1. NAMES OF STHEETe OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 6. LOCATION OF HOUSE SEWAGE DISPOSAL-SYTE SYSTEM OR PROPOSED <br /> 1. OUTLINE OF ED OUTLINES PROPERTY.GIVING ION OFIALL ANO NRTH mRECTO E EXPANSION F SEWAGE OISPTHIN RA I SOF ON <br /> ]. DIMENSIONED NCLDING CO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS PE ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WAIXS. ON THE PROPERTY OR ADJOINING ROPFRrv. <br /> DEPARTMENT USE ONLY <br /> APPIIA.Aecytetl BY <br /> Gr U BNPe sw BY D.te <br /> DsO.ion 1I .I.By <br /> Da'S <br /> DOTTanU: � <br /> ACCOUNTING ONLY: MDI FACT <br /> PF COOED FEE INFO AMOUNT REM?TED CHECK/gAsH RECSVEO Y DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />