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1 APPLICATION FOR WELLlPUMP PERMIT <br /> AN JOAQUIN COUNTY PUBLIC HEALTH <br /> SERVICE'1 ` <br /> ENVIRONMENTAL HEALTH DIVISION <br /> s 'P,O, 80X 388, 304 EAST WE13EAVENUE, STOCKTON. CA 9526,1388 <br /> i {203) 460.3420 <br /> NON-REFIINDARL_E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICRmpI/t/ In T11plie/t/] r a <br /> Y FOR A PERMIT TO CONSTRUCT AND/On INRTAL.L THE WORK DESCR18ED.THIS AiPPLICATIO <br /> APPLICATION IS HERE BY MADE TO THE SAH JOAQUIN COUNTN IS MAGE IN COMPLIANCE W"f!SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE„CHAPTER 9-1115.3 AND TI it STANDARD9 OF SAN JOAOUIN COUNTY PVBLfC HEALTH SEnVICEB,FNVIRONMENTAL IIEALTII DIVISION. <br /> I <br /> J08 ADDREBBlpR APH+I - <br /> r CITIQ PARCEL 8176APN/ <br /> OWNER'S NAME ?�'y� e\' '� f�� ADDREBB 2900 0—' 7 MIONE <br /> CONTRACTORek 1U -��y���r.}j, //JJ <br /> ADDRF,RS O� cLr/_ .?>M <br /> SUS CONCONTRACTORo,I ��yy,,�n�'CTOR� �, q �p <br /> !c, +��GJ O� inN r t� <br /> TYPE OF WELLIPUMP: Lyp HEW WELL ❑ REPLACEMENT WELL LS MONFFoniNn WELL i <br /> __5. t ,1 <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑CROSS-CONNEC ❑ OTHER_' I� <br /> T REPAIR y ❑ VAPOR EXTRACTION WELL I <br /> f1YPE OF PL1MP1 <br /> ❑New❑Rep.lr H.P. DEPTH PUMP SET FT, FIRST .. - ! , <br /> WATER LEVEL O <br /> ❑ OUT-OF-SERVtCF WELL ❑ OEOPIVSICAI_WELL I ❑ SOIL PORING <br /> DE9tnvcrtGN: i 8 <br /> INTENDED USE TYPE WCONSiRUC ICON SPECIFICATION/ 6. <br /> ❑ INDUSTRIAL ❑OPEN RO TTDIA.OF WELL g-/ -- _�� '4 <br /> ��� ELL E%CAVA7IOM ¢IA.OF CONDUCTOR CASING <br /> 11 <br /> DOMESTIrMAIVATE LIE ORAVEL PACKID17F 0 TYPE OF CASINO7STEF1 Vr� DIA.OF WELL CASING �� a <br /> 11PUBLICM1uNICIPAL ©DRIVEN - a D <br /> DEPTH OF OROUT REAL_ - SPFCIFiCATION,��' � R <br /> �❑ IRRIGATtONIAO ❑OTHEn GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> 19 MONITORING 0I-T4�7�. ��66 ��--77� E <br /> f GROUT SEAL PUMi'EO: ❑Ys. L11:fln CONCRETE PEDESTAL 8Y DNLLfR•❑Ver LT.YFI. S <br /> APPROX.DEPTH —LOCKING CHF %16r.OVE.MS?E - -� <br /> Ii1OP09ED CON/TRUCTIONJDRIlLIN a METHOD: MUD ROTARY AIR ROTARY,s AUGER V CARLF OTHER <br /> } <br /> I HEREBY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION on <br /> THAT THF WORK WILL RF DONE IN ACCORDANCE WITH SAN JOA O JN <br /> COUNFY'iORO1NANCEB,>iTATE LAWS,AND RULES AND <br /> RFOULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWMEn On LICENSED AGENT'S SIONATUnE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> 11118 PERMIT IB ISSUED,181 IALL NOT EMPLOY PERSONS SUBJECT TO WOnKMAN'S COMPENSATION LAW$OP CALIFORNIA.' CONTRACTOR'S HIRING OR SUR-CONTRACTING SIGNATURE CER71FFES <br /> THE FOLLG%MNO: 'I CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,191EALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEIY/AT10N LAWS OF <br /> CALIFORNIA.' THE AP IT MUST CALL 24 HOURS IN ADVANCE FOR ALL RFOURED INiPECr1ON/.JAT 1209148@_4 2a. COMPLETE DRAWING AT LOWER AREA F'110VipfO.d <br /> Stoned X <br /> TRI <br /> PLOT PLAN IDrrw Is Berle)9er1r <br /> R- 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE PSOPEnTY. <. LOCATION OF HOUSE SEWAGE DIRPOSAL 9Y9-rrM On PROPOSED 1 <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRFCTION, EXPANSION OF SEWAGE DISPOSAL 11YeTEMS. P <br /> 7, DIMENSIONED OUTLINES AND LOCATION OF ALL EXIRTINO AND PnOP0Bf4 <br /> S. LOCATION OF WELLS WITHIN MhfUe OF ONE HUNDRED FIFTY F7. <br /> BTRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. :+ <br /> ON THE PROPERTY OR gpj0lNINO PROPERTY, <br /> 7� <br /> r- -w fag - a <br /> V,;, <br /> _ ...,,. <br /> .F <br /> - 1 <br /> DFPAn TdRFNT USE ONLY <br /> Ap411c0�111o_nAceepy� — .._ .. - - Drlr G [ Ars. <br /> Orem In.peetlon By De1e P1rmp Intper Uen ey l/ Dae <br /> De.lO,elFen irnpebetlon} _. <br /> ACCOUNTING ONLY; AID# FACT r(o� <br /> �Jb L <br /> ;1 <br /> PE CODE/ FEE INFO AMOUNT REMITTED CIIEC KIlGA9H RECEIVED BY .GATE PET,MIT//TRVFCE REOUE/T Nt1M8B1 INVOICE � <br /> Pub.Health Serv.-Enviro.173(3196) <br /> _ ;� jn <br />