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-j;APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEAk"fff <br /> ,I ENVIRONMENTAL HEALTH DIVISION <br /> P.6 BOX 388,3D4 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> -I' 12091 490.3420 <br /> y NtlM•REFUNDADLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> II. ICemphts In Tr1pREetef <br /> APPLK;A7MN IB"FRE BY MADE TO THE SAN JOAQUIN cOUNTY:Pon A PERMIT TO CONSTRUCT ANDM"INSTALL IMF WORK bESCRBED.THIS APPLICATION Is MADE IN COMPIANCE WITH BAN <br /> JOAOVIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,tm%nsaNMENTAt HEALTH DIVISION. <br /> Job AboRtSelofl APN! 56 A(CR-h ,tel L7c (7 R 3 r CITYv PARCEL SIMAP t <br /> T <br /> OWHFA'E NAME S•!. MiAfAe5 1+ -� S C 41c1.% ADDRESS F+.m PLPGNE! .l 7�357q <br /> COMPACTOR AQVrzMC>?�l /L^C 4 t! ?a;vcn7!•�T.4 AObRESR iSL"1 1f.4rf7,.lFiMt�1 L FN�_�_LICE/.4'OCI7 PHONE!�l.'ftW•ylF7T/ <br /> OUR CONTRACTOR 0'I4JY Cc✓, l ,v r,# ADd1ESB�J i.`is�./'���A�O,Ja J�Yi� FUc/��LPHONE���f�"Q4� <br /> TYPE OP WEU PUMP: ❑NEW WELL ❑REPLACEMEFrt WELL ❑MONtTORNO WELL F ❑OTHER <br /> ❑INSTALLATION ❑WELL BYBTEM REPAIR ❑CRO99-CONNECT REPAIR ❑VAPOR EXTRACTION WELL f J <br /> ❑Hex❑Fl p.h H.P. 3 {€� btpTH PUMP SET_FT. FIRST WATER FEVEL O <br />{ ITYPE OF PIMP I y kE <br /> ElDVT-OF-SEflVICE WELL ❑OEOPHYSCAL WELL lI SOR eORNG ! S <br /> ❑DEBTRI/C7ION: � � <br /> INTENDED LIFE TYPE OF WELL ,I 1 CONETBVCIIOM/pECIFICAIlONI A I <br /> AJ INDUSTRIAL ❑OPEN SOT-rem )': ;3 ''R DIA.OF WELL EXCAVATION /J�,7�' I INA.OF CONMICTORCASIMO MIET D <br /> ❑DOMESTIC/PIVATE ❑GRAVEL PACK/ETLE TYPE OF CASMOFSTEELIPVC Ni�^� DIA.OF WELTCABINO D <br /> ❑PUSLK MLtwtPAL ❑DRIVEN � „ DEPTH OF GRDUFT SEAL "/C�rry,7l Jp' � EiECIFICATION <br /> ❑t MMA7tONIAO ❑OTHER �� GROUT SF,AL rNSTALM13 BY I PLIMI S� OROUT BRAND NAME O A - E <br /> I]{MONRORNO / 1 :^'I' ® ' -1 TIN. 3 <br /> AP PDX.DEPTH -�S_--------- ---- - ' GROUT SF/1L0 KING C"❑E#TtR BOX//STOVE PIPE CONCRETE PEDESTAL 0Y DRILLER:❑Yr d <br /> PROPOSED CONSTRLICTONMR ILLOW METHOD: MUD ROTARY_'.' AIR ROTARY AUGER CABLE ot"Vn. <br /> I NMOY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGVIN COIMTy ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE BAH JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIINATURE CERTIFIES THE FOLLOWMO:'I CERTIFY THAT IN THE PERFORMANCE OF 1'HE WOMIK FOR WHICH <br /> TIDE PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT 76 WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTort's NIR140 OR SUS-CONTRACTING BIOMAT IBE CEMIFtEB <br /> E THE FOLLOW WO: -r cEMrrY THAT IN THE PERFORMANCE OF TME WORK FOR WHICH TWO PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT To WORKMAN'S COMPPMATWPI LAW#OF <br /> c ALTFORMA.' THF APPLICANT MUST CALL 24 NOUPO IN ADVANCE FQR ALL REGIRRED INBPECTIONI AT ILMI 4p4422. COMPLETE tMAWING AT LOWFR AREA P vrDED. I <br /> k Rlp.wd x L.l��A.} �3 I$ TI". <br /> ROT PLANto,—I.M61.1 ESN. le <br /> L. NAMES OF sTREETs OR ROADS NEAREST TO OR SOUNDINO THE'fT Oftr TY. - 4. LOCATION DF HOUSE SEWAGE DISPOSAL THEM OR PROPOSOD <br /> 2.OUTLINEOFT <br /> PROPERTY.GIVING DIMENSIONS AND NORTH DI11ECMN. EXPANSION Of SEWAOE DISPO# �,� <br /> 3.DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PLIOPOEED I. LOCATION OF W 1119 WITMN lJ#RF.ONE WFNORED Fir"FT. <br />{ STRUCTURE#,MCLUDINO COVERED AREAS SUCH AS PATIOS,DIVVEWAYS,AND WALKS. ON THE PROPERTY OR AOJOININA'Iyit)PERTY, 'I <br /> 1 ; <br /> 2 5 X996 <br /> .. �rll II- ,Efi } <br /> E3 <br /> ISI <br /> iTF,t IiChk,Ikl <br /> I . <br /> ji <br />' <br /> r <br /> 1E <br /> L , <br /> , <br /> -,.......,. - .. ........ ...... ... <br /> el'2 11 ;i DIAARTMENT USE ONLY <br /> APPR..Ibn A.."od BY � D.I. v IJ A— <br /> G,.N Impnelhn BY 'hS 0.1. P1 p Imp—don By DNe <br /> D..nu.rl.n Irep..e.A By IE <br /> D.le <br /> I, <br /> C—m-m �! <br /> I : ,r { <br /> { <br /> ,r <br /> -c—TING ONLY: AID! FACE <br /> PE COD" FFEINFO AMOUNT nIEMITIFD HECI AEH RECDVED■r DATE PERMITMERVICE AMUEST"ween; INVOICE <br /> 99. ; <br />