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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JDAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O,BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201588 <br /> 1209)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICAT (CBmpki1 iB TTlpRe4t4) <br /> JOAQUIN ON N HERE EL MAGE TO THE SAH JOACHAPTER <br /> 9-1115.3 <br /> -N COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE wnrit SAN <br /> JOAOUtN COUNTY DEVELOPMENT TRLF,CHAPTER 9-7 I I$.3 AND THE STANOAROS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. ) ,y <br /> JOB ADORESSX)R APIN�IJ^Q Q PARCEL SIZFJAPN/_/ �,[�•C;•J^C�^ <br /> OWNER'S NAME L`1/n'l/4 z- �lL�L�1..-� ADDRESS�n�n lJx� ST�� gHAO/ PHONE I_71/��� _ <br /> CONTRACTOR; �j/.meq e; ADDRESS/�Y (.rj Y �1P(�j 579�1J1C1_7,�PFIONE <br /> ADD 37 R1 '1 F YF�u, PI4ONE 1 <br /> few-�zT?•.T <br /> TYPE OF WELL/PUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL♦ ❑OTHER L <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL 0 J <br /> (TYPE OF PUMPI 11N_13R-1, Mr. DEPTH PUMP SET_F t. FIRST WATER LEVEL O <br /> ❑OTT-OM1 SERVICE WELL ❑GEOPHYSICAL WELL <br /> / ❑ SOIL BORING B <br /> VVESTRUCTIO.F SNC f%A/l'if d••v �77A-%-, ,s7 e, 4,111- f <br /> F <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑INDUSTITAt trttl BOTTOM ~ ^ <br /> DIA.OF WELL EXCAVATION -)•- DIA.OF CONDUCTOR CASING .4f0^'Y4f O <br /> ❑DOMEStIC4 IVATF ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING <br /> ❑PUBLICRJUI.+-r, ❑nmrri DEPTH OF GROUT SEAL /D/ SPECIFICATION R <br /> ❑IRRIGATION;- L]OTHFn GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MOHNOrIN,, GROUT SEAL PUMPED:11Y— [IN. CONCRETE PEDESTAL BY DRILLER:[I Y- N. S <br /> APPROX.DEPTH V41 <br /> _ LOCKING CHESTER BOX/STOVE PPE S <br /> PROPOSED CO" METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTP +PRFP.AFO THIS Arf'LICATION AND THAT THE WOW,WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGLMTIONS ..TUM COUNTY.HOME OWNER On LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS M'., L IAT FI..PLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,'CONTRACTOR'S HIRING On SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOW t. ­l M THE rEnFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' <br /> .wM+fy lL 24/HOIgS IN ADV.#&s FOR ALL REQUIRED PUIPTCTIONS AT 112.0�*1 4gJA23.COMPLETE DRAWING AT LOWER AREA PROVIDED.. � <br /> SIEn.4 x /J-I' / /AL/�✓'-' TRI. / �1 ! "• �/- <br /> 7i <br /> KOT PLAN HDr.w M ScWI 6e.4�_•to� <br /> 1.NAMES OF• - r MIT TO OR eounno JG THE r"o ERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2.OUTIME Or .+.n...—41ISIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 0.MMENSIOPK .M -nN OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES. COVERED AREAS SUCH AS PATIOS,DWVFWAYS,AND WALKS. ON THE PROPERTYOR ADJOINING PROPERTY. <br /> r <br /> �P <br /> jqY. . ss <br /> ...... .. ... . .. <br /> ..... <br /> ....................I .. ..... ....... <br /> ....... ... <br /> ..... .. .... <br /> Ir <br /> ... .. .....Tar <br /> DEPMTMENT USE ONLY <br /> App^.e.11on AtteP:M BT [� D.1. Ar ✓ O <br /> Groin Irrp.etbn BI_ - D.t. Pump In.Pklbn BY D.t. <br /> Oe.lruotbn Im Ilrxr B• A O.t. <br /> CnmmsN.: <br /> ACCOVNTIND OHL Al.. FACT <br /> PE CODES IEE TKO AMOUNT Rt.ITED CNE I ASH RECEVED SY DATE PO"T/SERVICE REQUEST NUMBER INVOICE <br /> n z <br /> 600i <br /> o�L r4 1 <br /> Pub.Health Sam.-Enviro.173(3/96) <br />