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APPLICATION FOR VVEMPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 398,445 N.SAN JOAQUIN ST,STOCKTON,CA 95201.389 <br /> 1209]4883420 <br /> NON•REFUNDIM PERMIT E%PEKES 1 UAR FROM-PAIL 1111sulpv <br /> (CaBgIBb In TriPOFahf <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOIAN COUNTY FOR A PUINUT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE^YAT <br /> JOAQUIN COUNTY DEVELOPMENT THU.CHAPTER NO m IMI Rd m RC <br /> 9--1115.3 ATHE MANDDAARDDS�OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> Joe Rowse O,APHI Ibi"71 E AtoTC -�T PAEL SLMA" t,Q E.J <br /> OWNER'S NAME " �7 ADORESS i r PHONE a Jfp 1 -101(t <br /> D <br /> CONTRACTOR S -�.'E 'pij M�ET.7 �L 21� .+ ADDRESS P OAa PHONE a55 <br /> SUB CONTRACTOR ADDRESS UCO RHONE P <br /> TYPE OF WELUPtIMP: ❑NEW WEU. ❑REPLACTMENT V.TLL 11MDNITORpNR WEIR r 13OTHER <br /> [3 VN INSTALLATWELL SYSTEM REPAIR 13CROSSCoNNECT REPAIR 13VAPOR EXTRACTION WELLI J <br /> 0 N_orR .N H.P. ` DEPTH PUMP SET_FT. FIRST WATER LEVEL O <br /> fTYPE CF RIM% <br /> ❑OVT-0E-BLNVICE weL ❑OEDPHYSICM wELL• ❑ SDR BIKINI a <br /> ❑DEITTHyCTION; <br /> IMDIDED USE TYPE OF WELL CONSTRUC ON SPECIFICATIONS A <br /> ❑{INDUSTRIAL 13 OPEN BOTTOM MA.OF WELL EXCAVATION OM OF CONDUCTOR CASINO D <br /> D OOMESTICIPRIVATE 13 GRAVEL PAouazE TYPE OF CASiNGMTEUPVC DIA.OF WELL CASINO O <br /> ❑PUBIJCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A <br /> 13 IRRIOATIONIAG ❑OTHDH OIIOUT SEAL INSTALLED BY GROUT BRAND NAME a <br /> ❑mOHITO1TNO ORoUT SEAL WMPED:❑Y_ ❑Ne CONCRETE PEDESTAL BY DPLLFR:❑YM ON. a <br /> APPROX.DEATH LOCKING CHESTER BOXTSTDVE PIPE g <br /> AIOPOBFD CONiTRUCT10x101IW NO METHOb:AIIIb ROTARY AMMOTARY AUGEFI CABLE OTHER <br /> I HEREBY CERTW TIWT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JDAGIAN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGU THINS OFTHE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOEIIT'S SIGNATURE CERTIFIES TIE FOLLOWM:•I CERTIFYTHAT W THE PERFORMANCEOF THE WOW FCR WHCH <br /> THIS PEMArT IS ISSUED.I SHALL ROT EMPLOY PERSONS SVRJECT TO WOROAAN'S COMPERMTWX LAWS OFCAUFORMA.-CONTRACTOR'S HIROIG ORSUI CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWINO: •I CERTIFY THAT IN THE PERTOSMANCE OF TRE MPIK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOLIDMAN'S COMPEFIAATION LAWS OF <br /> CA ;A. {EASST �r ARIOFD INB►ECTIOIM AT 12MI NfiL7i.COMPLETE DMWNAT POWER --�yDEM`, � <br /> III _ZTp <br /> �—� <br /> PLOT PLAN O@ m Sa.Hf Saw 1 LI ^to r I.E 1 1 <br /> 1,NAMES OF STREETS OR RDADS NEAREST TO OR BOUNDING THE PROPERTY, 4.LOCATION OF HOUSE SEWAGE OISPOBAL Syff"M OR FMFCSF13 <br /> t.OUTLINE OF THE PROPERTY,OMNI DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATIOH OF ALL EXISTING AND PROPOSED B,LOCATION OF WELLS WITHIN RADIUS OF ONE IIRIOAED RFTY FT. <br /> STRUCTURES.SICLVDWO COVERED AREAS SUCH AS PATIOS,ORIVEWAYS.ANO WALKS. ON THE PROPERTY OR ADJOHNNNO PROPERTY. <br /> ..,:. ... ...: -..,.-,...c <br /> Q <br /> iY <br /> . : ....... ...... <br /> EE\ <br />( ..,.. a. .. .. ....,, .....,,� .. .. ..t.. .. .... <br /> I _ <br /> n. ,. ... ... _ <br /> 4PAYA :. <br /> r`'R1 F <br /> . :.� AUG.2 1998 <br /> PIN t�LINT! IS <br /> .... - .... i. .:....,, ...,,... <br /> PU13I,1CHtALTEi 611FV E <br /> - .LNYIflGN141E1d1'At <br /> APPS.San Aaspmtl BY <br /> DEPARTMENTDEPARTMENTTMFDEPARTMENTINE ONLY .._.. <br /> OM Z.r Z' <br /> 6rmS L'NPFFHIan Of v DBmPLENP NrPbSen SYS A O <br /> D�tw I-p-6 n By D— <br /> CommP,mG � <br /> I <br /> ACCOIAFRHO ONLY: AIOO PACO <br /> PE CODES PEE ICNFO ANI <br /> ONT REMITTED IEC ABN MAIM SY CATE PERMITpORRCE PEOIIBFT Ntonot INVCM.I <br /> V r_ <br />