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1 <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> e� SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 45202 <br /> (209) 468-3420 <br /> 11011•AEFUNDA011 PERMIT EXPIRES 1 TEAR FROM DATE ISSUED <br /> (Complete In TF011ostel <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PEWAIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLES.CHAPTER 8-1115.3 AND <br /> DTHEE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMBION, <br /> JOB ADDRESSIOR APN � Q- ` -C /( +.�. �j CITY S- Lf r PARCEL S1.ZPJAP14I y <br /> OWNER''NAME [. ADORES' ` ` /4- _ JJ �� - PHONE t 73- _ft P 0 <br /> CONTRACTOR '� - DOREBB _ UA <br /> 1 "Of/ <br /> //�10 <br /> Stro CONTRACTOR I -4OIJ f S ADDRES, 'f r _- / �� PHONE <br /> TYPE Of WELLIPUMP: Q'--TW WELL © REPLACEMENT WELL LkJ'NONITOWNG WELL f OTHER' <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> TRYPE OF PUMPI <br /> 11 N.(3VEL Rapal/ H.P. DEPTH PUMP SET FT. FIRST WATER LEO <br /> ❑ OUT-OF-SEAVK:E WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_-9_1 I-_____ DIA.OF CONDUCTOR CASINO V <br /> ❑ DOMESTIC/PRIVATE GRAVEL PACK/BIZE... TYPE OF CASINO/STEEL� DIA.OF WELL CASINO A a <br /> 11PUSLICIMUNICIPAL ❑DrmN DEPTH OF GROUT SEAL;, — �� SPECIFICATION �r S <br /> ❑ IRWGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY T).'/ � /^ GROUT BRAND NAME - �� .•,.. � ,: <br /> OWFORING-_ w I GROUT SEAL PUMPED: CJYwI [In. CONCRETE PEDESTAL BY DRILLER:❑Yao []No S <br /> APPROX.DEPTH T{}/ ' LOCKING CHE'TE OX VE PIPE - S <br /> PROPOSED CONtTRUC110NIDGELUNO METHOD: MUD ROTARY AIR ROTARY AUGER ,CABLE OTHER <br /> I HE-WRY CERTIFY THAT 1 HAVE FREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY, IGOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN''COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIWNG OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOVANG: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,G SHALL EMPLOY FERSONS SUBJECT TO WORKMAN-6 COMPENSATION LAWS OF <br /> CALIFORNIA.' THE CANT MUST CA HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT I201t 449-2421. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> elon.d X_. f lA L✓ Tlfle -- f �L T� Date_. 7- <br /> PLOT PLAN IDrow to Seolel Scala •ro <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDOM THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPDSED <br /> 2, OUTLINE OF THE PROPERTY.OIVING DMONSIONB AND NORTH LIIIECTION. EXPANSION OF SEWAGE DIBPOS,LL SYSTEMS, <br /> 3. DIMENSIONED OLITUNIFE AND LOCATION OF ALL EXISTING AND PROPOSED I. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAB SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> i <br /> DEPARTMENT USE ONLY <br /> f <br /> Applleatlen Aoaepted BY^� Date . X1 -> Arae f - <br /> 7 <br /> OrmA Impoetlen By Date Pu,P Inopeetlon By Dote <br /> O-Inretlen Impeetlen BY Data <br /> ACCOUNTING ONLY: ANDD FACS <br /> r <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK/ICA/H RECEIVED BY DATE PER ITMERVICE REQUEST NUMBER INVOICE <br /> Pub Health Serv.-EnvirG.173(1/97) <br />