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f0 <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION COPY <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 L <br /> (209) 488-3420 <br /> NOHUUNDANEE PERN it EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION N HERE BY MADE TO THE SAN JOAOL,IN COVHTV FOR A PERMIT TO CONSTRUCTNS <br /> FAnvion INSTALL THE RT M <br /> TrIpIketal <br /> E WOSCRIRED"THIS ArPLICATIOH 18 LfAbt IN H COFRPLIAIICF WITRAN <br /> JOAOUIOApU1N COUNTY DEVELOPMEHi TITLE HAPTER 9-1 11 g•3 AND TPE.STANDAIIDS OF BAN JOAOUIHrCOUNTY 1 lIC HEALTH SERVICES,ENVIROHMENt A!IIEALTII DMMON, <br /> " J r I ,�'I <br /> JOB AopRE68/RR AF'Nf 1. � C(' <br /> ' "`LLL <br /> OWNER'$.NAME ��r�1 ,. - PARCFL R12ElAIyNf <br /> _ ADORES$ .• _ .�l.�yr�� �'f4 111 I r ��[� �" } <br /> CONTRACTOR ",ONE <br /> .. `,V AbT"a ,/. <br /> AIM CONTRACTOR ll� U`T/� f- �1'{IOHF I__ <br /> Abb11E89 <br /> LI <br /> CO- PHONE <br /> TYPE OFLEL MP' ❑ HEW WELL _ PLACEMENT WELL ❑ MONnoRiNO WELL I <br /> ❑ INBTAL.lA710N I.1 OTHER <br /> LL eYR7EM REPAIR ❑ CnORB.CONNECt REPAIR �y <br /> Cl VAMR ENTMCTNTN WELL f f <br /> ❑New❑Req Nr II.P"... - DEPTH PUMP ACT FT. <br /> RVP'E O�� F PVMPI EiRBt WATER LEVFI���_ n <br /> ❑ OUT-0F-SERVICE WELL ❑ OEOP11YBICAL WELL I ❑ g011 R0111NO B <br /> ❑DESTRUCTION; <br /> INTEINbEp ULE TYPE OF W CONSTRUCTION SPECIFICATIONS <br /> ❑ INOIfSYR+AL ❑orEN ROTrOMLNA <br /> A.OF WELL EXCAVATION DIA.OF CONDUCtOR CARING <br /> ❑ DGMESTICIPRIVAtt ❑GRAVEL PACIClBL2E n <br /> TYPE OF GROUT B ALII'1/C GIA.OF WFLL CASINO-� o <br /> ©FURLICIRNUNICIT'AL ©61IIVENI <br /> DEPT 14 OF GROUT REAL <br /> 11 $IFCI►ICATION <br /> IRMIGATION,AO ❑OTHER GROUT SEAL 1NBTALLFD BY R <br /> ❑MONITORING GROUT BRAND NAME E <br /> OROU7 REAL T1/M1'ED;❑Yr ❑Ne CONCRETE PEDESTAL BV ORI ' <br /> APPROX.at � LLER;IJ Yr ❑Ne i <br /> LOCKING CHESTER BOX/OTOVE TYPE <br /> PROPOSED CONSTRUCT1ONIMMILUNG METHOD: MUO ROTARY AIR noTAnYs <br /> AUGER CARLOj_OTHER is <br /> I NE9EBY CERTWY THAT 1 HAVE PREPARED ime APPLICATION AND THAT TRIF WORK YYIU.BE DONE IN ACCORDANCE WITH BAH JOAOI,lN COUMY QGMAHCE/.STATE NWB,Al-RULER Aup <br /> ItEOULATIONS OF TNF SAN JOAOM COUNTY, HOME OWNER OR 0CFNBED AOENT'R e1ONATURE CERTIFIER THE FoLLDWING:'1 CERTIFY 1HAT IN THE PEEKpRMANCE OE TILE WOI-FOR WICK. <br /> T1110 OLtOH IS ISSUED,I RIMLL NOT EMPLOY PERBOMB BIIBJECT TO WORKMAN'/COMPEN/AT10N LAWS OF CALIFORNIA.• CoNT1TACTOR'S NStlNG OR R1,6-COMRACTMIO SIGNATURE CETTTIFIEF <br /> TILE FOLLOWING; •I CERTIFY THAT IN THE PERFORMANCE OF TILE WORK FOR WHICH TNI$pfrdL T I$N,*WD,I SHALL EMPLOY RACPenO R'SUBJECT TO WOIIIrMAN'e COMMN/ArieN TAWS O9 <br /> CALMORNIA,• THEA CANT M T CALL 14 HOUR{IN ADVANCB FOR ALL REOUIREb M/FiCTWNe AT 12",44W"tq <br /> . eOlunt.ETF eMWING AT LOWER AREA PIgVIbED, <br /> Signed <br /> rm. !. <br /> FLOT/LAN IOr■w le BeNai&.1. 'to <br /> 1. NAMES of STRE"I1 OR ROAOR NEAREST TO OR BOUNDING THE tRpPERTV, <br /> 2, OUTLINE OF THE PAOPERty.OIVINO DIMENSIONS AND NORTH DIITECiION. 1. LOCATION OF I EWA SEWAGE DLBhygTt RYBIFM OR PROPOSED <br /> $. OLMENRIONED OUTLINES AND LOCATION OF ALL Extern AND PIbPoREo EXPANSION F: SEWAGE DISPOSAL SYSTEM$. <br /> BTMXT1nTEB.INCLUDING COVERED AREA►OWN At PATIOS.DRIVEWAYS.AND WALKS. /. LOCATION OF: TY O WI7TNIT1 MOR/$pF . ILUHORED FIt'TY FT" <br /> ON THE WbI�IRY OR AOJOIRNO PtTOFERtY• <br /> / 57 .17 <br /> ... + <br /> - r•,i irk,I 1 .+ <br /> Ad� <br /> v <br /> ;I, <br /> PEVARTMERT USE INLY <br /> APelie■!Mn AeaepteA BY � � V� b.1. � ( C Arr <br /> O,etM In■Pna1Mn By pat■ IN—v I—p—don By <br /> 0.w111c0en 1n■P+rtlen Ry <br /> Dole <br /> t �J <br /> ACCOUNTING otftY; AID/ .FACE <br /> PE CODER TEE INFO AMOUNT REMITTED CHECK ASH RECEI BY DATE <br /> PENaRITf/ERVICE REGUE$T NUMBT3L INVOICE <br /> --� C <br /> Pub Health Serv.-EnAro.173(1197) <br />