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F'� <br /> OLEO <br /> � <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERM11 EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TI'IpBal.) <br /> APPLICATION 18 HERE SY MAOE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.TINS APPLICATION 18 MADE M COMPLIANCE WITH SAN <br /> 1 JOAOUIN COUNTY DEVELOPMENT TRUE.CHAPTER 9- 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEMTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSiOR APNO S � /� CRY C PARCEL SIZEIAPNI / <br /> OWNER'S NAME FL ADDRESS D PHONE 0 <br /> CONTRACTOR ADDRESSZZI O D i.IC- 62 OZ PHONE/ <br /> ^ SUB CONTRACTOR ADORE <br /> 1 ' <br /> TYPE OF WELUPUMP7 11NEW WELL ❑ REFLACEMENT WELL ❑ WIONRORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> ❑Hew❑P"* H.P. DEPTH RUMP SET FT. FIRST WATER LEM 0 <br /> RTYPE OF PUTAP1 <br /> E3OUFAFSERVRCE WELL 13 OEOPHYBICM WELL I 604 BORING 4 .JV2- B <br /> ❑DE6TRUCTbN: <br /> INTENDED USE ns.OF_W CONfTRUCTHIN_ePEO1FtC:A)TONi '4 <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM GIA.OF WELL EXCAVATION __.,,,_ <br /> DNA.OFCONDUCTORCASI NO D <br /> T^ ❑ DOMESTIC/PW VALE ❑GRAVEL PACxmrt TYPE OF CASINO/STEEL/PVC OIA.Of WELL CASINO 0 <br />�- ❑ RUKxmJUWCiPAL ❑THRIVEN DEPTH OF Wow SEM �O SPECIFICATION R <br /> r ❑ IARIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORINGtJ ., GROUT SEAL PI/MPEm. ❑Yr ❑Ne CONCRETE PEDESTAL BY ORULLER Ely.* ❑Ne S <br /> APPROX.Dun" <br /> / �j LOCKING CHESTER BOXMTOVE RPE 5 <br /> Kv <br /> PROPOSED CONSTRUCTIONIDRLLIIIG METHOD: MUD ROTARY Ami ROTARY AUGER_,_CABLE OT"ElL ,_, <br /> .. I HE9ESY CERTIFY THAT 1 HAVE PREPAAED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES ANO. <br /> REGULATIONS OF THE SAN JOAOUM COUNTY. HOME OWNER OR LICENSED AGENT'S sm"ATURE CERTKIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERIIUT 1911SUED.1 BHALi NOT EMPLOY PERSONS SUBJECT TO WOMMAN'S COMPENSATION LAMS OF CALIFOIMA.' CONTRACTOR'S WINO OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWIII; •1 CERTIFY THAT IN THE PERPOFIMANCE OF THE WORK FOR WHICH THIS PEfIMR to woutD,1 SHALL EMPLOY PERSOINB SUBJECT TO WORKMAN'11 COMPENSATION LAWS OF <br /> _ CALIFORNIA.' THE APPLICANT MUST CALL 24 HO Ill AL1Y 9 FOR ALL INOURI%D ILfPQCTIDNe AT 1201114gy120. COMPLETE DRAWING AT LOWER AREA PROV10E0. <br /> Dote <br /> E ROT#IAN IEhew to Seato Setls M <br /> # 1. HAMS OF STREETS OR ROADS NEAREST TO OR BOU"bM THE PROPERTY. 1. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOBED <br /> 2, OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPAHS/ON OF SEWAGE DISPOSAL SYBTEIIe, <br /> 2. DNMENMNED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSEO I. LOCATION OF.WELL11 VMMN RAOR/S OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INNCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINM PFIOFIERTY. <br /> - <br /> 00 <br /> PAYMPEN <br /> .. .. . zip <br /> @ems <br /> � L <br /> I: ...... <br /> 1999, <br /> FEB I <br /> r��ALTII <br /> ENVIRONrOENTAt LTH 6vis <br />