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{ <br /> APPLICATION FOR WELL)PUMP PERMIT SCANNED <br /> r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 386,3O4 EAST WEBER AVENUE,STOCKTON.CA 85201ta';�� <br /> [209]488-3420 <br /> NON-AEFUNDASLE PERMIT EXPIRES I YEAR FROM DATE ISSUED i <br /> ICBlnpllU iR Ttblicahf <br /> APPICATIDN IS HERE BY MADE TO THE SAN JOAQUIN CDUNFY FOR A PERMIT TO CCNSTRUCT AND/OR INSTALL THE WORN DESCRIBED.THIS APPLICATION IHEDIVISION.COMPLIANCE WRH GAP <br /> JOAQUIN COUNTY DEVELOPMENT TNLE;CHAPTER 9-1115.3 AND THE STAND A SOF SARI JOAQUIN COV ,PUBUC HEALTH SERVICES,ENVTRON'MENTAt <br /> f { JOB AODRESSOR APN! oC S T <br /> CIN PARCEL 82FIAl'NI --c.�pry i•/c��/a�J <br /> 1 OWNER'S NAME ADDRESS r ITIONE lJ J�(7�q /'"r <br /> CONTRACTORlyr .k AODRF9A LIC! ZZ PHOHE43-3? 5'Z <br /> CONTRACTORSUB LIC! PHONE! <br /> ��ff FPry� <br /> i TYPEOF WELUFVMP: 13+NEW WELL 13 REPLACEMENT WELL ❑MONITORING WELL/ 0 OTHER <br /> I <br /> I I❑-Y INSTALLLTioN ❑WELL SYSTEM REPAIR ❑CROSS EPNNECT REPAIR ❑VAPOR EXTRACTION WELL! J <br /> 4J New Q P-1Y H.P. DEPTH RUMP SET_FT. FIRST WATER LEVEL - p <br /> STYPE OF PUMP) <br /> ❑OUT-OP-SERVICE WELL ❑GEOPHYSICAL WELL! ❑ SOILBORING g <br /> ❑ <br /> DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRMTIDN SPFCIRCATIOAA f A <br /> ❑INDUSTRIAL �❑yOPEN BOTTOM DIA.OF WELL EXCAVATION �j��/� GIA,OF CONDUCTOR CASINO �` p <br /> ❑DOMESTICRRIVATE YO.GRAVEL PACXIBII'E TYPE OF CASINGIGTEELP/C P1/.� OLA.OF WELL CASING r p <br /> ❑PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIRCATION A <br /> 91MOATIONIAO ❑OTHER GROUT SEAL INSTALLED BY MdjW1111GROUT BRAND NAME D .� - E <br /> ❑MONIT07VNG / GROUT SEAL PUMPEO:91 <br /> r DR. CONCRETE P'EOESTAL B LIRA I Pn.❑Y- x- S. <br /> 1i APPROX.DEPTH —7�+ LOCKING CHESTER BOX/STOVE PIPE S <br /> ? PROPOSED CONSTRUCTIONIOANLING METMO:MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> L 14MOY CERTIFY THAT!HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WDH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATION G DFTHE SAN JOAOUIN Ca UNN,HOMEOWNER OR tICENSED AGENT'S SIGNATURE CEMIFIES THE FOLLOWING:'I CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY PERSONS SUIWECTTD WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HOLING OR SUOLONTRACTING SIONATVRE CERTURES <br /> THE FOLLOWING; -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WMICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORNIA.- TME APPLICANT MUST CALL Y HOUR!1N ADVANCE FOk ALL REOWREn INiPECTION4 AT IzoBl 1!i-S42d,COMPLETE DRAWING AT LOWER AREA PROVIDED, <br /> I rC f <br /> 6Ilrnd x_ �/!t, Y�JI�Tn�J/,Y{�.i+a- <br /> PLOT PLAN IS_W G_I.I P;!e •w <br /> I,NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDIND THE PROPERTY. 4. LOCATION of HOUSE REWAGE OtGPDSAt SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THF PROFFRTY,GIVING DIMENSIONS AND NORTH bIRECTION. EXPANSION OF SEWAGE DISPOBAL SYSTEMS. <br /> G.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF.WELLS WITHIN RADIVS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> � I <br /> ...... <br /> 4 <br /> �... ........................ ....... <br /> ...................................... .......j' "" <br /> r <br /> .......... <br /> 4 . <br /> ........... <br /> ............ <br /> ....... ....... <br /> ...........: <br /> .... ... <br /> NQV 1-Z IWL. <br /> - o.....''..' f .;....ENVIRDMMENT"EAL7H dIV510N E <br /> ... .... _ <br /> DEPAATMENT USE ONLY <br /> APP/-1-A,,W d By .l One <br /> (S Grout lm Peetlon BY L D.I. ��� 'J PInnP ImPacUon BY Dale <br /> • De.IrOeAen Nr.P.etlen BY <br /> k De[e <br /> cemm«x0 <br /> • f ACCOUIYTINQ ONLY: AID! PAC! <br /> PE CODES FEE INFO AMOUNT REMITTED ICHECK CASH Rt-OvEO BY DATE PERMITMEAVICE REQUEST NURSER INVOICE <br /> lay 7S z <br />