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,} APPLICATION FOR WELUPUMP PERMIT <br /> SANOPWAOUINCOUNTY PUBLIC HEALTH SEF�'ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Com <br /> kis In <br /> APPLICATION IS NERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE MH SAN <br /> JOAQUIN COUNTY DEVELOPMENTT TITLE,CHAP'T'ER'9.111/1165.13 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC H ALTH SERVICESS,,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODMSSMR APN1_ ''0Jz az/M 1 � CNy.�J �� �i+ PARCEL SIZE/APNI <br /> OWNER'S NAME &A4f <br /> q!�ADDRESS PHONE l <br /> /�,� /�1/^ GL/ <br /> COMMCTOR—,/// <br /> IyEJ O l�Z{�1 ���JL�.�J 4 <br /> ,1 ADDRESS <br /> �� �j� UC1��_PHONE I�� <br /> BUB CONTRACTOR IlA/J�K ADDRESB CEJ CG� f—ILY\ .mo(M1017 PHONE <br /> 191�- <br /> TYPE OF WELUPUMP: P❑1 ANEW WELL ❑ REPUCEMENT WELL ❑ MONITORING WELL I /❑ HER <br /> ((II <br /> W INSTALLATION ❑WELL SYSTEM REPAIR ❑ CMIL"ONNECT REPAIR / APoR EXTINCTION WELL I A-I GC 5 j <br /> ❑Naw❑Reeab N.P. DEPTH RUMP SET-FT. 1`FIRST WATER LEVEL O <br /> rlY OF PUMPI <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ SON BORING e <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS.Q L q <br /> ❑ INDUSTRIAL ❑O NBOTTOM DIA,OF WELL EXCAVATION F> DIA.OF CONDUCTOR CASING /V�-1- D <br /> ❑ COMESTICMRIVATE �VEL PACK/SIZE TYPE OF CASINO/STEEIIPVC DIA.OF WELL CASINO D <br /> ❑ POBUCR.IUNICIPAL ❑DNVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ABOUT SEAL <br /> ❑ MONNONNOO T/❑OTHER <br /> INSTALLED <br /> OROUTSEALPUMPED: ❑Yr [IN. CCRETEEPEDESTALSYDWLI-QNe 5 <br /> APPROX.DFPTN I LOCKING CHESTER SOX/STOVE RUPEE - S <br /> PROPOSED CONSTRUCTUMUDOULUNO METHOD: MUD ROTARY AIR ROTARY AUGER - CABLE OTHER <br /> 1"MAY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LOINIGM AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY REASONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S WANG OR BUDCONTRACTINGSIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THSJ PPICANT MUST CALL 24"DIMS IN ADVANCE FOR ALL REOMRED INS TIONS AT MOST 488-128. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> ftX � �f Till. Dna �-// J• <br /> PLOT PAN(M.to Seale)Bella 'to <br /> 1. NAMES OF STREFTB OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE$MADE DISPOSAL SYSTEM OR PROMISED <br /> Z. OUTLINE OF THE PROPERTY,GIVING OIMENSION6 AND NORTH DIMCTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING ANO PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE NUMBED NFTY FT. <br /> STRUCTUREB,INCLUDING COVERED AREA$SUCH AS PATIOS,DNVEWAYS,AND WALKS. ON THE ROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY <br /> APPnenlen AeeepLad er -Cyt�f/—�. �� wl. -7/L)/4 <br /> OmU Bnpstl.n Br Ons Pune IMP..Ben By Dna <br /> bmm<Ibn ImPww.BY Dna l <br /> C.n-..: "TO 1p <br /> ACCOUNTING ONLY: AID/ FACE <br /> PE CODES FEE INFOSUNT REMITTED CHECKFICASN RECEIVED BY DATE PBRMITIIEIMCF REOVEeT NUMBER INVOICE <br /> SOI112.2 co <br /> Pub.Health SSW.-Enviro.173(1/97) <br />