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APPLICATION FOR WELL,/PUMP PEFO <br /> S: .'JOAQUIN COUNTY PUBLIC HEALTH S.; ;;VICES <br /> ' ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 _ <br /> NON•REFUNOAU�E PfRMIF EXPIRES 1 YEAR FROM DATE ISSUED <br /> fcompla(v <br /> III Tr1pnele1q) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT INSTALL THE WOW(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE YVHH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 11 6.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL,HEALTH?DIVISIO 1 <br /> JOB ADDRESSOR APNN 70c C El /A ra CL.o "v CITY 5.�0 ��,�� f-3 " " �'C7 <br /> OWNER'S NAME-��dr I-N S* 7 �r f^1 / PARCEL 81ZEIAPN# I OQ3 130( ADDRESS -10 �• past J6 PHONEI�a yam'746 q <br /> CONTRACTOR AQVQ -L +0 VII r KNIyrt,r`Q ( ADDRESS Qd Iv. �li f�M 4 2 r^ <br /> CUB CONTRACTOR Ltc� PF16NE R 6 7-`00 4 <br /> ADDRESS LICE PHONE N <br /> TYPE OF WELLMMP; ❑ NEW WELL © REPLACEMENT WELL ❑ MONITORING WELL I <br /> - ❑ INSTALLATION IJ WELL E]WELL SYSTEM REPAIRCROSS-CONNECT REPAIR 13 OTHER <br /> ❑ VAPOR EXTRACTION WELL s J <br /> ITYPE OF PUMP [I Now ClRepairH.P. DEPTH PUMP SET FT. <br /> i FIRST WATER LEVEL 0 ya <br /> ❑❑ <br /> DESTRUCTION; oUIC - <br /> T-OF•8ERVE WELL ❑ OEOPHIL Y6ICAL WELL# ® COBORING F <br /> H <br /> lNTIF110ED USE TYPE OF WELL CONBTAUCTION SPECIFICATIONS❑ INDUSTRIAL 11 OPEN BOTTOM RIA,OF WELL EXCAVATION rT A <br /> ❑ DOMESTWIPRIVATE ❑ORAVEL PACKI8IZE CIA.OF WELL <br /> CASINGUCTOR IND 7„ D <br /> TYPE OF CASINp16TEEC/PVC � DIA.OF WELL CASING <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL T. P• r D <br /> SPECIFICATION _ R <br /> 1� XMIGATIONIAG ❑OTHER Onour SEAL INSTALLED BY GROUT BRAND NAME GIT 1 S K <br /> LL?MONITORING �, E <br /> GROUT SEAL PUMPED: ❑Vaa No CONCRETE PEDESTAL-BY DRILLER;❑Yw 11••++��1� <br /> APPROX.DEPTH - -LOWo S <br /> LOCKING CHESTER BOX/STOVE RPE <br /> PROPOSED CONSTRUCTIONIDWLUNG METHOD; MUD ROTARY _ ALR ROTARYT S <br /> AUGER CABLE OTHER I rt L 1 4 f <br /> I RMSY CERTIFY THAT 1 HAVE PREPAREO THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES ANO <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT 10 ISSUED,18l1ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTLFTES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T3416 PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORI(MAN'!COMPENSATION LAWS OF <br /> CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT"1444-2423. COMPLETE DRAWING AT LOWER AREA PROVIDED,.(.]`' <br /> -7-PL -bate 3-7- <br /> PLOT <br /> OT PLAN{Draw to aeNal Sale 'to <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUBE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE INSPOBAL SYSTEMS. E' <br /> STRUCTURES INCLUDING COVERED AREAS SUCH A8 PATf05,DRIVEWAYS,AND WALK8. <br /> _ WITHIN <br /> ON THE PROPERTY OR ADJDIUS OF E HU <br /> fFIfNOPROPERp+ <br /> DEPARTMENT USE ONLY /`�7j <br /> APPNurbn Aesoepted By -- "/ a'v O /0/ /t� <br /> 1 Data <br /> Gretrt Ir�pxtlen BI tv,! Pump Impaction By Date <br /> Umtrootlen Inapeetbn By ' <br /> �R ' pate <br /> Comments: <br /> ACCOUNTING ONLY: AID/ FAC! <br /> PE coolsAMOUNT REMITTED CHECKTICASH RECEIVED BY DATE PERMfTISERVICE REQUEST NUMBER INVOICE <br /> EE INFO <br /> 3 OT <br /> t . <br /> Pub.Health Serv.-Enviro.173(1197) <br />