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APPLICATION FOR WELLIPUMP PERMIT <br />' SAN JOAIIUIH COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 388,904 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209)469 9420 <br /> NOR REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IGmpkto In TiI lkat/l <br /> APPLICATION IB HERE BY MAWS TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT DA"INSTALL THE WORK DESCRIBED THIS APPLICATION IB MADE IN COM <br /> PUANCF WITII BAN <br /> AN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE CHAPTER O 1116 9 AND THE sTANDARIs OF BAN JOAQUIN COUNTY PUBLIC HMTH SERVICES ENVIRDNMENTAL HEALTH DIVISION <br />' S 1 57(1 r14La�!_ __PARCEL BIIEAAPHT ��C�`�U <br /> Jos ADDRRE". APNF 3 ~U. fr Clrr <br /> OWNERS NAME ADOREBB pO-r <br /> J r II /" AtIORESB LIC/ �� r PHONE /vc f <br /> CONTRACTOR <br /> PHONE <br /> C IOP <br /> N CSMh f7 �// ADDIIE/S ~ r/ ..{ ryw ,may <br />' TYPE OF WEISRUMP ❑NEW WELL ❑ REPLACEMENT WELL ❑MONITORING WELL/ ❑ OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS CONNECT REPAIR ❑VAPOR EATMCTION WELL E J <br /> ❑NM Q MOW H y DEPTH RUMP sET___-FT FIRST WATER WATER LEVEL y O <br />' ITYPE OF RUMPI ❑ WELL E OEORIYBICAL j.-F BOR BOPoHO <br /> EI OVT-0I BFRVICE WELL <br /> ❑DEBTRMIIQN <br /> iMTFJ1GEO Ul <br /> TYPE OF ELL CONS RUC IDM iFECIFICAHDMt � <br /> A <br /> ❑INOUBTRAL' 0 apiNSOTTOM DIA OF WELL EXCAVATION / DIA OF CONDUCTOR CASINO .Afl� D❑DOMESTICIMVATE ❑ORAVEL PACKISRE TYPE OF CABINOIEIrrury �-, I//I OIA OF WELL CASINO 0 <br /> ❑PUBUCAJUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ^ SPECIFICATION R <br /> ❑PWOATIOWAO TETHER C�' r 1+SCF [S'h'�{/ GROUT SEAL INSTALLED By,-/ r A� GROUT BRAND NAME F <br /> 0 IAoMTORNO f / GROUT REAL PUMPEP OY- ❑Nr CONCRETE PEDFSTAL BY DRILLER❑Yw DN- 5 <br />' APPRUK DEPTH ?A, LOCKING CHESTER 11011MOVE RPE 5 <br /> PROPOSED CONST%UCTIONIONLUNO METHOD MUD ROTARY AIR ROTARY AUOER CABLE OTHER <br /> I HEESIF <br /> Y CERTY THAT I HAVE PPEPAREO TIII APPLICATION ANO THAT THE WORL WGL BE DOME IN ACCORDANCE WIN$AN JOAQUIN COUNTY OROINANCEB BTAIE LAWS AND RULER ANO <br /> NOULATIONS OF THE SAN JOAOINN COUNTY HOME OWNER OR LICENSED AGENT S WONATURE CERTIFIES THE FOLLOWING 1 CERTIFY THAT M 7146 PEWPRMANCE OF i{IE NOIR FOR WHICH <br /> TWB PERMIT KiBBUEO I d1ALL1 NOT EMPLOKPER/OHS allsACT TO WCMMAN B COMPENSATION LAWS OF CALFORMA. COMRACTOR s HRSNO OR SUBCONTRACTING BIONATUM CERTFIES <br /> THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHMH TMS PEJRIIT I/ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENRATIGN LAWS OF <br /> CALLIFONSRL��THE AFFHD�A/N,T UVOT C 24 HOORs INA LCS FOR ALL MOLBRIP MSPSOTIONS AT/t,"I 4"4422 COMPLETE ORAWRM AT LOWER AREA PROVIDED / <br /> ! 6L�"/ Tllr. 'M f�Q wr� DM. <br /> K <br /> 1^ I PLOT PLAN LP.1..I.0.0-I—�• 1• ' <br />' I NAMES OF STREETS OR ROADS HEAREBT TO OR SOUNDING THE PROPERTY i LOCATION OF IIOVSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> OUTLINE OF <br /> THE PROPERTY OIVIRO DIMENSOHI AND NORTH DIRECTION EXPANSION OF SEWAGE q/fgSAL SYSTEMS <br /> a DIMENSIOWO OUTUNFIA <br /> S ANO LOCATION OF AL1 FXWTO AND P OPOSED S LOCATION OF WELLS WITIRN RADIUS OF ONE HUNDRED FIPTY FT <br /> STRICTURES.INCLUDING COVERED AREAS RICH AS PATIOS DW VEWALYB AND WALK/ ON THE PROPERTY OR A17JOlMN O PROPERTY <br /> 1 T <br /> 4 ` Fab <br /> e,, <br /> ) <br /> r <br /> I <br /> r /1--Trplr- <br />' DE/MTMOOT USE ONLY <br /> APW.III.f Awti1M SY - O.F. <br />' mw 6wP.LAFn Br D.I. PURIM Srp-0-1Y am- <br /> 0"—".R L.P..0-Br Da. <br /> I <br /> AceOVNTING ONLY AID/ FAC/ <br /> PE COOL EEE INFO AMOUNT REMITTED C ICABH RECEIVED sY DATE PERTIUREFIVICE EIEGUIEST NUMBER INY"CE <br /> ��L► 'moi °� /U�l l{� Z f`' 4�, II � t , <br /> Y <br /> I <br />' Pub Hsait"Sery EnYlro 173(3196) <br /> s <br />