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rr I <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES f <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON,'CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` <br /> lGampMN In TripRamfol ? <br /> APPLICATION IS HERE BY MADE TO THE SAH JOAOUIN COUNTY FOR A PERMIT 70 CONSTRUCT ANDMA INSTALL THE WORK DESCRIBED.TNKS APPLICATION IS MADE IN COMMIANCE WITH SAN <br /> JQAOUIN COUNTY DEVELOPMENT TIT11 <br /> LEE,CHAPTER 8- 115.3 AND THE STANDARDS OF BAN JOAOUIN COUHtYPUuB_LICc IHEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOS ADORESOMR APN#t R Ll T f— /� ff� CITY yec 4 PARCEL BIZFJAPNI <br /> OWNER'S NAME ADORERS 't ,�/ PmNE F. <br /> CONTRACTOR ADDRESS V7 S IR!�1 I YrT�6—PHONE 0 �L Z <br /> SUS CONTRACTOR ADDRESS LIC# PHONE# <br /> ���� <br /> TYPE OF WELUPUMP: WELL 13 REPLACEMENT WELL ❑ MONITORING WELL# 13 OTHER <br /> ryryryry <br /> INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR06"ONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> ❑Hew❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> . <br /> 11YPE OF PUMPI <br /> ❑OUT-0F-SERVICE WELL ❑ GEOPr1Y81CAL WELL 0 ❑ SOIL BONNNG 9 <br /> ❑DEBTRuCTION. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION! 17 A <br /> ❑ INOUGTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 't DIA.OF CONDUCTOR CASINO p <br /> ❑ DOMESTICWRIVATE :P(MRAVEL PACKIBIZE s TYPE OF CASIN0I8TEEUPVC j�P4 / DIA-OF WELL CASINO O <br /> ❑ BIJCMIUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION v R <br /> jRH14AT1ONIAG ❑OTHER GROUT SEAL INSTALLED BY OROUT BRAND NAME aG E <br /> MONITORING GROUT SEAL PUMPED: ❑Yr ❑we CONCRETE PEDESTAL BY"RILIFA:❑Yee Ne 5 <br /> APPROX.DEPTH �// LOCKING CHESTER BOXMTOVE PPE S <br /> PROPOSED CONSTRUCTIONUOWLLINO METHOD: MUD ROTARY ]� AIR ROTARY AUGER CABLE OTHER <br /> I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPUCAM04 AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH BAN JOAQUIIN COUNTY ORDINANCES,STATE LAWS,AND RULES AHO <br /> REOULATIONS OF THE SAN JOAOUM COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CEHTIflEB THE FOLLOWING:-1 CERTIFY THAT IN THE PERTORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 10 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORMA.' COWRACTOR'8 HIRING OR SUB-CONTRACTMO SIGNATURE CERTIFIES <br /> THE FOLLOWING: IFY THAT TT PERFORMANCE OF THE WORT(TOR WHICH THIS IS ISSUED,1 SHAD.EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of <br /> CALIFORMA,' _ CANT M C 24 HOURS IN ADVANCE FOR ALL REDUIIIm NNi N0 AT 1200}4"4422, COMPLETE DRAWING AT LOWER AREA PROVIDED. yry <br /> RIO <br /> Title Dm• "` I5' L <br /> P. Ce- <br /> T PLAN Rhwv to Boole$Salve 'is <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,O1VINO DIMENSIONS AND NORTH DmECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2. DIMENSIONED,OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> BTHUCTURER,INCLUDING COVERED AREAS SUCH AS PATIOS,OWVEWAYB,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> ��. <br /> A6x�` <br /> : <br /> c-�f <br /> lrr <br /> tv <br /> rr <br /> ninT <br /> i <br /> .. <br /> ... .. . ..... . <br /> ., .. E <br /> r <br /> i&lb <br /> 5 <br /> EtdVIR4NMEW AL FfFr4f Tii UIVS�RVJCE5 <br /> I <br /> t DEPARTMENT URE ONLY ,( / <br /> Application Aeaapted By ✓ Dole <br /> Grail*wpeellen BY 4 Dag/ Pump hwpaerten By Otte <br /> DaelnreRlern Irwpoatlen BYTrr- Date <br /> Commer,e+' ' <br /> ACCOUNTING ONLY: Aro# FAC# <br /> pE coon FEE INFO NUIOUNT REMITTED C ECKI ASH RECOVED BY DATE PEHMITUlm-PACE REGUEBT NUMBER INVOICE 3 <br />