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T <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 /> X011-111FURDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ <br /> ICampletE In TT1pRcM.1 <br /> APPLICATION 16 HERE BY MACE TO THE SAN JOA---COUNTY FOR A PERMIT TO CONSTRUCT ANDA INSTALL THE WORK CEBCRIRED.711TH APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAOVIN COUNTY DEVELOPMENT T(TU.CHAPTER S.1�1-13�'�.3VIRNF <br /> ANMD THE STANCAman OF SAN JpAOUIN COUNTY PUBLIC HEALTH SERVICED.ENVIRONMENTAL HEALTN DSIGN, <br /> JON AOCAESSMR T7-5-60 <br /> AMM W /m rj <br /> L�PARCfL 812EJhPNI <br /> OWNER'S NAME «'y��.., �_/AyW. �'✓w ADORES. <br /> 4t DL5 <br /> p �7 LJ'C�7J: <br /> CONTRACTOR �(JEl4+ ��L7iAI � AO4.S&gAI/0 f3^•L4i4.ti. 11C, EMONE/ �J�� I <br /> SUS CONtRACTOR AROMA. 'Y <br /> LIC! PHONE• I <br /> �E <br /> ctrl TYPE OF WELLA'ISMP: {❑-I NEW WELL ❑REE(,ACENENi WELL S.J MON/TORIN01YElL I ❑OT11FR _ <br /> lJINVII A--L,LATION ❑WELL/♦�DYY.T EM REPAIR ❑C"""ONNECT REPAIR ❑VAPOR EXTRACT"N-EU <br /> I J <br /> 0 E. <br /> Nr P-4 H.P. /v DEF?N PUMP AEFeFT, FIRBl WATER LEVEL O <br />^^• IIY7f OFPUMPI IC�-T �1---FF <br /> ��_L..J OVTAF SERVKE WELL <br /> 4l GEOPHYSICAL WELL I ❑ ROIL RORINO a <br />�`� ❑DESTRUCTION: I <br /> INTENDED UEE TYPE Of WDLL CONSTRUCTION SPECIFICATIONS A <br />•— F❑,INOUSTMAL 0f--IOPEN BOTTOM DIA.OF WELL EXCAVATION OfA,OF CONDUCTOR CABMq O I <br /> 4J DOMESTnC PFFVATE 1F_II GRAVEL PACK1812F TYPE OF CADING/ET EEIAP CIA-OF WELL CASINO O <br /> Ef -8Uc"UNiCmAL 0 DRIVEN DEPTH OF GROUT SEAL GFIECIHCATION R <br /> 0,�-1 1RRIOATIONTAG ❑OTHER GROUT SEAL IN07AL ED BY FT--l1 GROW BMSA NAME ��II E <br /> j LJ mowrommo GROUT SEAL PUMPED:❑Yw 1J N. CONCPETE PEDE8TAt SY nRLLER'❑Yr O N. ,7 i <br /> APPROX.D[PYH' �K II LOCKIHO CHE.EER R01178TOVE APE j <br /> PROPOEEO CONSTRUCT64MLVNO METHOD:MUD ROTARY AIR AOTARY AVOER CABLE OTHEP, . <br /> 1 HERESY CERTIFY THAT I HAVE PREPARED THIS AP"JCATION AND THAT THE WORK WILL eE DONE of ACCORDANCE WTT71 SAN JGAOUIH COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> I <br /> REOVLATIONE OF THE SAN JOA.COUNTY,HOME OWNFA OR LICENSED AGENT'S 61ONATURE CERTNIER THE FOLLOWMO:'I CERTIFY"AT IN THE PETTOrUAANCE OF THE WOM FOR WNfCEI <br /> THIO PERMIT.. <br /> E1WR IS 168VE0,I EIIALL NOT EMPLOYI+ERSONS.VIIJECT TO WORKMAN'S COMFdEAT,ON LAYY.OF GALDPPErtA.'COHTMCTOR'B HIPoHO OR SVDLON7AhCTp14 SIGNATURE CFATIFIE. <br /> THE FOLLOVANO: •1 CERTIFY THAT M T11E PERFORMANCE OF THE WOW FOR WHICH THIS PENAD M ISSUED.I SHALL EMPLOY PERSONS SVDIECT TO WORKMAN•.COMFOISATION LAW,OF <br /> CALIFORNIA.- THE CANT MUST C }A HOW IN ADVANCS TOR ALL REOISRFO IN.FE,CTIDN.AT f2 l 4M3423.COMPLETE OMYYIM AT LO <br /> WEfl AREA PROVIDED. (� <br /> j elm�ed 7f TIH. rf12-L-�� <br /> PLOT/lAK IN—I.S.o S.M. <br /> I. A.E.NOF STREETS OR ROADS NEARERT 111110 UHDMG THE PROPERrY. A. LOCATION OF}PURE dEHO <br /> WAGE D18POTAL SYSTEM On PPORED <br /> 2.OUTLINE OF THE PRONMONRTH <br /> PERTY,GRANO DENS AND NODIRECTION. EXPANSION OF EFWAGE DISPOSAL EYETEMV. <br /> �.OIMEN810NEO OVTLMF.S AND LOCATION OF Att E alma AND PROPoSFD E. LOCATION OF WELL.WM M RADIUS OF ONE HUNDRED fITTY FT. <br /> STRUICTVRER,w LVOINd COVERED AREAS SUCH M PATIOS DRIVEWAYS ANO WALXd ON THE PROPERTY OR ADJOSNn1G FPOpERTy. <br /> -'..- .. .v.. . <br /> 4 <br /> :. .. {... <br /> 3 <br /> T.r {f'LAi Y4 t141-T r1J1.'•.L r- -. <br /> pU413 rycrs[Ai..1i. <br /> L V DEF flIT VSELNlll <br /> APP1rF.n..,Aay.elnA e■ L mu Ar.. L(J[C_J <br /> O,eu IrARe.11en Sr 0.1. hFnP Mwn11.n DY O.1• <br /> Dasni,4�1-11 n aF D.e. <br /> I <br /> i <br /> ACGOV-ONLY: AID/ FACT <br /> PE COOEI FEE INMED <br /> FO AOI.T R ITTC CX 1CAFH RECfJVEO BY DATE FORMITFSE[VICE REOVEST NUMBER INVOICE <br /> R�{ I <br /> 1 Pub 4RBI1h Sam-Enviro.173(1197) <br />