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APPLICATION FOR WELLIPUMP PERMIT <br /> F SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES DO <br /> ENVIRONMENTAL HEALTH DIVISION �NED <br /> P,O.BOX 388,304 EAST WEBER AVENUE,STOOMN,CA 95ml W p1Y <br /> I 1204]400-3420 <br /> s t / <br /> P NON•REFUHUABLE PERMIT EXPIRES 1 YEA0.F90M DATE ISSUED 1 � <br /> t IGmpMh In TdplicaE61 i <br /> I APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPIJANCE�yOJf�Fi SAI <br /> JOAQUIN COUNTY DEVELOPMENT TELE,CHAPTER 9111 5.3 AND THE STANDAg06 OF SAN JOAQUIN COV PUBLIC HEALTH BFRVICEB,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORES6RR APNI ♦ ex I crrY J L/L d2d-''-1 PARCEL 82ElAPH,T <br /> . v OWNER'S NAME—,L T&t A DRESS/(S�p� /p/7 Y1 _PHONE <br /> ( E / �.1` �T <br /> CONTRACTOR !I AODRE68�I�+41Xe,-f �LIC04W,8 2 2. PHONE/y�c—�� <br /> BOB CONTRACTOR ADDRESS NCI PHONE/ <br /> 4 <br /> TYPE DF WELVPIIMP: ❑NEW WELL AAEP ACEMENT WELL 13MONMORINO WELL• ❑-I OTHER <br /> 0 INSTALLATION ❑WELL SYSTEM REPAIR 11L <br /> CnDSSONNECT REPAIR 0 VAPOR EXTRACTION WELL/ <br /> I r i li{ <br /> (TYPE OF PUMP) L N—❑Re I, H.P. DEPTH PUMP 6FT_FT. FIRST WATER LEVEL 4 <br /> 131y <br /> OUT-o SERVICE WELL C7 OEOPHY6ICAL WELL/ CI SOIL BORING a <br /> STRUCT1oN / I &2La in <br /> _1r <br /> I�I•N•--�TrLNOEG USE TYPE OF WELL CONSTRUCTION SPECIFICATION, <br /> `� LE INDUSTRIAL ❑OPEN BOTTOM DIA.OFWELL EXCAVATION IDL'J DIA.OF CONDUCTORCASIN'G )� <br /> 1 _ E�T MESTIC—ATE Pf.W-L P-1,MIZE TYPE OF CASINGISTEEIJPVC r_ DIA.OF WELL CASING �� Q <br /> IL-1 PUBLICmUM'CIPAL 11 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION - p� <br /> TLI---.�TE IARIGATIOWAG ❑OTHER GROUT SEAL INSTALLED BYTI---LL GROVE BRAND NAME \� <br /> 1.3 MONETOWNG ED <br /> /•^/ GROUTSEALTVMP :I�r ON. CONCRETE PEDESTAL BYD LLER:❑Yw�ln 4 <br /> '4 APPROX.DEPTH_ �Li' J LOCKINO CHESTER BO%(STOVE FPE <br /> S <br /> PROPO,ED CONSTRUCT10N1D/CLNNa METHOD:MVD ROTARY AIR RDTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THATTHE WOWC WILL BE DONE 1N ACCORDANCE WITH SAN JOADULN COUNTY ORDINANCES,STATE LAWS,AND RULER ANC <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNEq an LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERRT.PMANCE OF THE WDWL FOR WHICF <br /> ' THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERM148 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAumnKIA.'CONTRACTOR'S HIRINO OR SUBCONTRACTING SIGNATURE CERTIRES <br /> THE FOLLOWING: 't GLKTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PEWATT 10 ISSUED,1 SHML EMPLOY PERSONS SVE IECT TO WORKMAN'S COMPFNBATION LAWS 01 <br /> CALITORMA,• T E APPUC�AyNT�MUST CR URS IN ADVANCE FOR ALL REOUIRED INS TIONS 7/2,11400)22,COMPLETE DRAWING AT LOWEq AREA PROVIDED. <br /> BlBrvtl MU <br /> nu. nELlpr' o.u�.J�< <br /> PLOT"'Ll"'Mm <br /> to <br /> Saelll Sole Ie <br /> 1,NAMES OF STREETS OR(LOADS NEAREST TO OR 1011 P IRO THE PHOFERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM UR PROPOSED <br /> 2,oLITUNE OF THE PROPFAEY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPAHBION OF SEWAGE DISPOSAL SYSTEM@. <br /> S.DIMENSIONED OUTLINES AND LOCATION OF ALL E=MN3 AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.- <br /> STRUCTURES, <br /> T:STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> ..... <br /> t <br /> ,.... ..... ............. <br /> .......... .. ........ <br /> ....... <br /> oto#f G f uE <br /> + :. �.� <br /> J 1998 <br /> ?U µFAI•�UHFIATN. Tµs� GNISta <br /> '�P1WIRQT1 <br /> .. ..... - L.c.. <br /> .., ..... - .... L <br /> I ....... .. ... e... ..a. ..... u -...... x <br /> LI� <br /> :.. .. . . <br /> .... :. � ld f <br /> n. . �—.. <br /> .. <br /> � T <br /> -- <br /> FL� <br /> yp �,.flJ^/ DEFARTNIOMT USE ONLY <br /> APPILee1WR Awe W BY lA R L- V`^{�(^{(-{/w�'W\ DNe <br /> Drou[Irnpeotlen By,� T��+r-.T.v� DNe��p� q�Rp Irapeellen By Dne De.a�Ll.,.I,,.P.�uo.Br D... '1,. -P - ' <br /> cprnmenl.: U•-C� � Sae •-tom-�-� 'Ze {�{""�' <br /> r2 e e T, t 7S—155r # -D O- 17 <br /> - ACC..NTIND ONLY: AIDS <br /> Y - PE CODES FEE INFO AMOUNT REMITTED CHECIUICASH RECEIVED BY DATE PERMIMAEPME REGUEBT NUMBER fJ tNVOICIE <br /> 1 two 01 o F�r3 <br /> a-oa j696 IKI ow Sla o448r <br />