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APPLICATION FOR WELLIPUMP PERMIT -.A <br /> AN JOAQUIN COUNTY PUBLIC AEALTN iEflihiliI <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKfON, CA iP�gg�• ` I E <br /> 1209) 488.3420 <br /> ! <br /> f�bN- MAY 8 <br /> AEFUII <br /> bABIE PERM E lRES EA A FAQ)Yf PATE ISSUEp _ 999APPUCA11 <br /> (Compl&b fn Triplils&L&) ��I���{'�111�� � N _�1_�H f <br /> JOAQUIN ON N HERE EL MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE yyOgE DESCRIBED THIS �.I � � <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER$-1 716.3 AND THE STANDARDS OF SAN ��.� �J`'I//`�'f►���''{++� 1 <br /> J08 ADDRESSIOR API f E ! JOAQUIN COUNTY PUBLIC HEALTH SEgV10E8,ENVIR6I,R�NEJILTH `CSIMOiNILi�A1VE WITH SAN <br /> rA- py,F f '1 <br /> OWNER'S NAME L ,p CITY r ,I PARCEL 8IZE/APNi <br /> CONTRACTOR ADDRESS WXSG7 p <br /> ± / <br /> I 6 �OJC aj-/ '.i PHONE I k <br /> ADORES a `� S � <br /> SUB CONTRACTOR LKO PHONE/ _ <br /> ADDRESS ! LFC/_ �]713 qBt�- 707 <br /> „PHONE r.Z7,4.21l7.� <br /> TYPE OF MP• ''I] NEW WELL ❑ REPLACEMENT WELL <br /> ❑ INSTALLATION 13 MONITORING WELL E I� ©OTHER _ <br /> ❑ WELL SYSTEM P <br /> H <br /> EJ Now❑Repair REPAIR <br /> H.P. REPAIR ❑ CROS&CONNECT REPAIR ❑ VAPOR EXTRACTION WELL. <br /> RYPE 0� p pUjdpl DEPTH PUMP 8E7FT, FIRST WATER LEVEL <br /> ,p{ ❑ OVT-OF-BERVICE WELL ❑ GEOPHYSICAL WELL/ 0 <br /> 15a ESTRUCTIOH: �!O/ 'jig.J'.._. -- - .. <br /> �._ -- -^-�_ � � BOIL 60RIN <br /> INTENDED USE - <br /> ���_ YPE OF YYELL FONT IJCTlO WFCIFICATION& <br /> Elii } <br /> INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION Ip <br /> 11DOMESTIC/PRIVATE ❑GRAVEL PACKJ812E - DIA.OF CONDUCTOR CASINO - D <br /> TYPE OF CASING/STEELlPVC �� DIA.OF WELL CASING <br /> ❑ PUBUClMUNICIPAI' ❑DRIVEN DEPTH OF GROUT BEAU n` D <br /> ❑ IRRIDATK)N/AG ❑OTHER [[ ,9 <br /> GROUT SEAL INSTALLED BY SPECIFICATION <br /> 1 <br /> C3 MONITORING <br /> [36RpUT BRAND NAME MONITORING GROUT SEAL PUMPY. [3No `� E <br /> APPROX.DEPTH <br /> ! CONCRETE I ETE PEDESTAL BY DRILLER;[3yes ❑Ne $ <br /> LOCKING CHESTER BOXlSTDV£PIPE <br /> PROPOSED CONSTRUCTION'MAILLINO METHOD: MUD ROTARY 3 <br /> -- �AIR ROTARY,AUGER CABLE <br /> OTHER <br /> I HEREBY CERTIFY THAT 1 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 BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICI4 <br /> THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA'.' CONTRACTOR'S HIRING OR SVB•CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 ERTI T AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB 188UED,I8ALL EMPLOY PERSONS SUBJECT TO WORXMAN'&CbMPFN&ATlpN LAWS OF <br /> CAUFORNIA.• THE C UST C 24 HO IN ADVANCE FOIL All REQUIRED INSPECTION&AT 120Y1 4"-2422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed X T1t1• <br /> Dat• <br /> r, NAMES OF 8 E78 OR ROAA8 N PLOT PLAN(Draw to salol Sgala ! -to�_ <br /> NEAREST NS DR BOUNDING THE PROPERTY. <br /> DIRECTION. <br /> 4.�LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> z. OUTLINE OF H£PgOPERTY,GIVING DIMENSIONS AND NORTH DiRECTK)N. <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED :!EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, 8 LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ., . <br /> .. � ... _I it <br /> .. IA W. . <br /> EC X47.68 . . .: .EL:.4?,34 <br /> ,l <br /> I . <br /> PW 'islTindi ate, fflfl �q�, <br /> f... ... ..... <br /> ....... <br /> Mw .2.. <br /> _..,.EL.4?.6.6 ..:.. <br /> I <br /> V..6 P. . '........ <br /> rBODY SHOP:, <br /> CAL:IFO�N.[ <br /> .. WIL.bING �UPpL' <br /> :.. <br /> f .. i0Q0. . . 1.EvENH.... . <br /> TRACY, CJs1LIF' .. <br /> - r <br /> t <br /> DfpARTMENT U&E ONLY sl <br /> i�Application Accepted By Date_ In--�- �j ,A,. 07­t5 <br /> Gfoln Inspection By 'r <br /> Date Pump Inspection By <br /> ` Date <br /> t7e.Irµctlon iropeatlon By ,! Data <br /> Ccmments: <br /> ACCOUNTING ONLY: AID# PACO ..f <br /> PE CODES FEE INFO AMOUNT REMITTED !CA&H RECEIVED SY DATE PO WITIGERVICE REQUEST Nt1MRER INVOICE <br /> as°.2- 0- oCz <br /> i <br /> j , <br />