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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA SIMM- 88 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> _ (Complete in Triplieatel <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED,THIS APPUCATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ApOPE58/ORI APNB �/'- �[.. ' ! C�. T {�L''vf.i`i Ll:.vu/1 CITY l'[' r- PARCEL eIZE/APNI <br /> } <br /> OWNER'S NAME_ � 1 Irt� ��/11�C[�✓T 1 ADDRESS J� rJ �/ �Lr�.� /I/1I,/`> ?C PHONE FZSNySIr <br /> � `�:'jl <br /> CONTRACTOR CJ_ III- ,�7CL lS ADDRESS Z14; f7/'�✓'1 / ��(Is/,'UC,- '��ZPHONE R• Z�JJc�� <br /> L <br /> SUB CONTRACTOR ADDRESS LIC/ PHONE t <br /> TYPE OF WELLIPUMP:ALAIEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL B ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CTIOSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLS- J <br /> ❑N.❑Repel, H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP( <br /> ❑ OU1F-0F-SERVICE WELL ❑ GEOPHYSICAL WELL♦ ❑ 601E BORING B <br /> ❑DESTRUCTION: <br /> m <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS AG <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION `�5 'w DIA.OF CONDUCTOR CASING♦ D��' <br /> ❑ DOMESTIC/PRIVATE RAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING / Z- DR <br /> ❑ PImJc"UNICIPAL ❑DRIVEN DEPTH OF GROW SEAL SPECIFICATION R <br /> �mRIGATKOWAG ❑OTHER GROUT SEAL INSTALLED BY kGROUT BRAND NAME�ROq('4✓ T��� <SIC: E� <br /> ❑ MONITORING- ^ (� GROUT SEAL PUMPED:,�Y. CIN. CONCRETE PEDESTAL BY DRILLER:❑Y..0110 Sry <br /> APPROX.DEPTH �i//� LOCKING CHESTER BOX/STOVE REF SP, <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CARIE OTHER <br /> r <br /> r I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO' <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICRN <br /> THIS PERMR 19 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIE\ <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1$HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Op� <br /> CALIFORNIA.- THE APPLICA�NT,IMUST CALL,/ HOURS IN ADVANCE FOR ALL REOUIRED INEiPECTIOBS AT 12")4488{22. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> ` slv�.e X� 1 t_. L' •l LL-k.L,L"C4<,% TIo. V I L 14'K D.,..• �' �5�n <br /> PLOT PLAN ID'.I.SCM.($ 1. •t. <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 PL10PER1Y,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL$YSTEMB. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> to <br /> AY 1J S j <br /> Aik <br /> T`' CI`7J <br /> -MAIC 11906 <br /> � ML /EAI Tu D�VjIdI$IOI. <br /> " I ,� <br />