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��► 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 /> y� (209) 468-3420T . <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {CImpIBS6 in TrIpRclltfl J <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL_THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WIT II SAN <br /> JOAQUIN COUNTY DEVELOPMENT TMA.CHAPTER 9-1115,X3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRII:SSIOR APNE ( /�— T f CHY J�+L:�- /��� PARCEL BIZE/APN/ •'7cz dc <br /> �i Ll[� <br /> OWNER'S FIAME G "SCC 1116 AODREBS PmNE R <br /> CONTRACTOR ADO �]' <br /> RERS /• Ind Rt f�f �f - ,#ONE I.1lL <br /> SUB CONTRACTOR ADDMOO Ucf P/IONE f <br /> TYPE-OF WELL/PUMP: WEL! ❑ REPLACEMENT WELL ❑ MONITORING WELL f ❑ OTHER <br /> INBTALLATiON ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ vAPon EXTMCTIOWWELL I ./ <br /> ❑Hew❑Repdr H.P. OEPTH PUMP SET FT. FIRST WATER LEVEL p <br /> ITYPE OF RIMPi - '--• <br /> ❑ OUT-Of•SERvICE WELT ❑ GEOPHYSICAL WELLf ❑ SOIL BORING g <br /> ©DESTRUCTION: <br /> IM TENDED USE TYPE OF WELL CONSTRUCTION$I'ECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I DIA,OF CONDUCTOR CASINO p <br /> ❑ DOMESTICIP'RRVATE fi4RAVEL PACKMrZE ( TYPE OF CASINGISTEELH'VC__ � I DIA.OF WELL CASINO O <br /> f:'m <br /> ❑rIBMIMUNICI'AL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION 1 7; r q <br /> GATIONIAG OTHER GROUT SEAL INSTALLED BY _ GROUT BRAND NAMETORING GROUT BEAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLER:❑Ye.AN6 S <br /> APPROX.OEPTR LOCKING CHESTER SOX/SIOVE PIPE s <br /> PROPOSED CONSTRUCTIOIWDIILLTNO METHOD: MUD ROTARY 7l AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED TWO APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WIT"SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REOUTATIO"S OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTF-Y THAT IN THE PER►ORMA"CE Of THE WOPK FOR WHICH <br /> THIS PFMAIT IS ISSUED,I SHALL NOT EMPLOY PERSONA SINIJECT TO WORKMAN-2 COMPENSATION LAWS OF CAUFOF"X- CONTRACTOR'S HIRING OR SUB-CONTRACTWO SIGNATURE CERTIFIES <br /> THE FOLLOVJIHG: IFI THAT TI PERFORMANCE OF THE WORK FOR WHICH TFII6 RIB ISSUED,'I SHALL EMPLOY PERSONS SUBJECT TO WOR$MAN•><COMPENSATION Uwe OF <br /> CALIFORNIA.' ANT.M C 24 HOIAI{1N ADVANCE FOIL ALL REGURBD INs NB AT 12M1 4q. 11. COMPLETE DRAWING AT LOWER AREA PROVIDED. cc ��7y <br /> Signed Titl. O.t. "�__f/71 I �. <br /> 4 <br /> rix T FLAN tD¢...re Ba.I.I Be,a •e. ' <br /> 1. NAMES Of.STREETS OR ROADS NEAREST TO OR BOUNDING THE F'RDPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> Z, OUTLINE Of THE PROPERTY.GIVING o1MENS10He'AND NORTH DIRECTION. - EXPANBIOH OF'REWAOE DtOPOSAL SYSTEMS. <br /> I. DIMENSIONED OVTUNF.B AND LOCATION Of ALL EXISTING AND PRDPOSEb I. LOCATION OF WELLB WRTHIN RADWA OF ONE HUNDRED FIFTY FT. <br /> STRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE FROPERTY OR ADJOINING PROPERTY. <br /> ..... <br /> ch Ply <br /> : <br /> . . . <br /> w <br /> ... .. ,r ...... l'118LJZ'N Y <br /> HSA TI�f i <br /> FI VIRONMENT T Q V Si N <br /> _:_ •. �:� <br /> X&J <br /> � • OEPMTMLIIRT UAE ONLY - <br /> n / <br /> App9e.sn Mia <br /> e .Pled B7 D.1 (e'.•_.T_Ar.. C - <br /> Grer¢I M»peatlpn BRA. Dft#/ Pimp hwpeellen BY b.la <br /> tle.lructlen lu.pectlon BY�L <br /> CemmerKr_ _ <br /> i <br /> t <br /> r- <br /> ACCOUNTING ONLY; AIDE _ FACS- <br /> PE COGES FEE INFO AMOUNT REMITTED C IEC%! AsH " RECEIVED my, , DATE PIS ATMERIVICE REOUEBT NUMBER <br /> 4J3Afll <br /> 'k <br /> Pub 4eaHh Sem-Enviro-173(1/97) } <br />