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APPLICATION FOR WFLLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERV,1400t <br /> ENVIRONMENTAL HEALTH DIVISION '1 <br /> P.O.BOX U8,304 EAST WEBER AVENUE,STOCKTON.CA 95201388 . ) <br /> (209)468-3420 <br /> NON-REFUNDABLE PERM11 EXPIRES I YEAR F1101A DATE ISSUED. <br /> lCerfiplets <br /> APPLICATION 16 HERE BY MAGE 70 THE SAN JOAQUIN COUNTYFGq A PERMIT TO LONBTgUC7�ANOlORkINSTALL THE WORK DESCRIBED.THIS APPLICATION IS MAGE IN COMPLIANCE WITH BAN <br /> ` JOAQUIN COUNTY DEVELOPMENT TILE,rC+H(AMEjR�B-111_16.3 ANDD THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH PIOSION. <br /> 7 <br /> JOB AVORESSIOR APNN �C "V r/V�V /� '"-r �-�l CITY • 11'G <br /> � <br /> W PARCEL BIZFJAFN/ <br /> OWNER'S NAME 1"tV_ ADDRESS 1- W: D(-e k-,.� 'T` -� 2.0 PHONE <br /> COHVIRACTOR C ,_••_ADORESSEZIE�b'TO 6+ fLL <br /> - <br /> "CONTRACTOR � 7 "� PHGNE ESL <br /> 1JMCVu1�E ADDRESS 0 -07;z`l Z3( <br /> N•+vV\� .LICK.(p L'T 4J PHONE <br /> TYPE OF WELIJPUMP: ❑NEW WELL ©REPLACEMENT WELL ❑MOkrtORIHa WELL P ©OTHER - <br /> ❑INeTALL/ETION '❑WELL SYSTEM REPAIR ❑CRVAPOR F1fTM <br /> OSS-CONNECT REPAIR <br /> CI N—0R.p d, H.P. - CT <br /> ON <br /> {TYPE OF PUMP) DEPTH PUMP BET`_PT. FIRST WATER LEVEL Hi <br /> ❑OUT-OF-SERVICE WELL ❑OEOPryeICAL WELL,/ ❑ BOIL BORINa - ' <br /> B <br /> ©DESTRUCTION• <br /> NTENaEP <br /> La g- <br /> ILP94F ffM CONSTAIICtIO !SPECIFIC ONi <br /> ❑INDUSTRIAL 06PEN BOTTOM DIA.OF WELL EXCAVATION�` - A <br /> PIA.OF CONDUCTOR CASINO I <br /> ❑DOMESTIC/MVATE �t�CK/SURF Q,6�Il _A.. 0 <br /> TYPE OF CABINO!BTEEUPVCf?yL crGhr. VIA.OF WELL CASINO h <br /> ❑PUBUJCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 14 JJ D <br /> El SPECIFICATION �— R <br /> INIGATGNlAG C3 OTHER GROUT SEAL INSTAILEO 6Y 'lICJ <br /> pp�� GROUT BRAND NAME £ <br /> MONITORING GROUT SEAL PUMPEO:❑Vw UN. ! ppTT . <br /> 1S CONCREIEPEDEUTALBYOwLIEFt..Myw ❑N• 3 <br /> APPROX.DEPTH � <br />- fFN NESTER B� BTO VE PPE 1(, - <br /> PROPOSED CONSTRUCTIONONrLLINO METHOD: MUD ROTARY _S <br /> AIR ROTARY AUOEREy[ CABLE -THEq - <br /> 7 HE4ESY CERTIFY THAT I HAVE PREPMREO THIS APPUJCATION AND THAT THE WORK WILUBE DONE IN ACCOPUMCE LMTN BAN JOAQUIN COUNTII p-INANCEB,STATE LAWS,ANp RUIEB AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CH{TtFIES TUE FOLLOWING:'I CERFIFV TUAT ON THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMrt IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WCPIKMAN'S COMPENSATION LAWS OF CALIFORNIA.*CONTAACTOR'B HIRING OR SU'"ONTRACTWO SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WoOW FDR WHICH THSB PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICAIRT Mini CALL 7411OL1i8 IN ADVANCE FOR ALL RFGUIRED INSPECTION&AT IJOSI 4".14;5. COMPLETE DRAWING AT LOWER AREA PRO DEB, <br /> Blend)[ P-r J' '— <br /> K. r <br /> PLOT PLAN 1DrPw[•8•M•1 So,N.' •Ip <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY, <br /> -- UNE OF THE PROPERTY,GWINO DIMENSIONS AND NORTH DIRECTION. 4, LOCATION OF HOUSE SEWAOE DISPOSAL SYSTEM OR'PROpos[p ' <br /> MENBIONEB OVTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED EAPANB(GN OF SEWAGE DISPOSAL SYSTEMS, - <br /> / S. LOCATION Of WELLS WITHIN 11Ab1U8 OF ONE HUNDRED FINN FT. <br /> SUCTUAEB,INCLUDINGOVNFS COVERED TION SUCH XI PATIOS.D PROPOYB,AND WALKS. <br /> OR ADJOINING PROPERTY <br /> JqAW <br /> • �, <br /> oO - <br /> �' <br /> J SW I Crozcry <br /> 1 <br /> y5o r,A,AI <br /> 0 oLL <br /> EL <br /> rzw)v <br /> Al <br /> r <br /> cwt <br /> 4 <br /> C ..,_...... <br /> o a- <br /> a ~ U - -- DEPARTMENT USE ONLY <br /> C <br /> fn AaP.Pled BY .. .. ✓ 1�.�f <br /> GrOnl IMpeetlPn SY D•t• P%pAp In•P•.I.n eT ' <br /> D.t• <br /> pwlrvollan HMP•.II•n BY , <br /> Du• <br /> Cpn.Mnb:. - <br /> ir - <br /> ACCOUNTING ONLY: AUDI FACS' - <br /> PE <br /> CODES FEE INFO AMOUNT REFATTSO CHEC"ICASH RECEIVED BY PATE PHRMITT&ERVICE AEaUE@T NUMBER <br /> INVOICE <br />