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APPLICATION FOR WELL/PUMP PES 'IT <br /> &MR JOAQUIN COUNTY PUBLIC HEALTH -,vtAVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 fi <br /> (209) 4W-3420 l <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I1 L L' <br /> (Complete In Triplicate) <br /> APPLICATION 1E HER BY MADE TO THE RAN JOAWIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WHIZ SAN <br /> JOA WIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN MAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOSAWRESSNR ASR/ (Q'f� WV G T CITY LA7'HR0x;' <br /> y7 f7 _,t f �j PARCEL BI2F/APNI <br /> OWNER'S NAME.�e Z CNA R aI "yNO ADDRESS .p/�.C/I /7/rJ}( q-1 <br /> CONTRACTOR SON �:Jy�I,�l/Eti/ ADDRESS r -D. /�B f( 3�JJ��/t'Jq� UCF PHONE I � <br /> Run CONTRACTOR 7r"_/- h ADDRESS L>; J 7j/ LICE PHONE <br /> TYPE OF WELLIPIJMP: ❑ NEW WELL ❑ RPLIICEMENT WELL ❑ MONITORING WELL I •_ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> WATER REVEL O <br /> 11Naw11J <br /> Repair H.P. DEPTH PUMP SET R. FIR"DVFE OF WM% <br /> 1:1 DESTRUCTION: Hy <br /> ❑ OUT-OF-SERVICE WELL LYl GEOPHYSICAL WELL#---t— ❑ Son.SONNO <br /> B <br /> INTENDED USE TYPE OF WE CONSTRUCTION SPECI <br /> ❑ INDUSTRIAL ❑OPENSOTTOM FICATIONS 11 <br /> _11 A <br /> PLA.OF WELL E%LAVATION PIA.OF CONDUCTOR CASINO <br /> 11DOMESTMIPRIVATE 13 GRAVEL PACK/SITE TYPE OF CASINOISIEELJI'VC PLA.OF WELL CASINO D <br /> D <br /> PUBIICRAUNICIPAL 11 DRIVEN DEPTH OF OMM SEAL M4CIFICATION <br /> ❑ IRRIGATION/AG ❑OTHER GROUT REAL INSTALLED BY °ROIR BRAND❑ NAME cIl I YYIc.I`F E <br /> ❑ MONNOmNG GROUT SEAL MMPLD: ❑Vs Na CONCRETE PEDESTAL BY DRILLER:❑YN Ow <br /> APPROX.DEPTH 1 (.� LOCKING CHESTED NOXNTOVE OPE <br /> S <br /> PIIOPOSED CONSTRIRCTIONIDNlUNO METHOD: MUD ROTARY AIR NOTARY AUGER CABLE OTHER <br /> I HERBY CERTIFY THAT I HAVE PREPARED THIN APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,"ATE LAWS,AND RULES AND <br /> HEMLRATIONB OF THE SAN JOAQUIN COUNTY, HOME OWNER 09 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,WHALL NOT EMP Y I ERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWN OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIONATURE CERTIFIES <br /> THE FOLLOW!": IFY THAT 11 1 PERFORMANCE OF THE WORK FOR WHICH THIN PERMIT IS IBSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CO <br /> CALIFORNIA.- T1 /F�tCANT MU C IIOLIIO IN ADVANCE FOR ALL KEOUNIETI INSPECTIONS AT MOq 460-5423. COMPLETE DRAWING AT LOWER AREA PROVIDE MPFMSAl10M LAWS OF. <br /> MB^.K X / • TRI. Oat/NE� <br /> D.I. 7 <br /> PLO LAN IM.m SeN.I t.,. •le <br /> 1. NAMFS OF STAFF-Fir09MADS NEAREST 10 OR BOUNDII TNF PR°PEnIV, S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR I ROMSED <br /> T. OUTLINE OF TIRE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND RoMSEO <br /> DIB. S. LOCATION OF WELLS WITHIN NRADIUS OF ONE HUNDRO HFTY R. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WA <br /> ON THE PROPERTY OR ADJOINING PROPERTY. ,^�• <br /> n\ <br /> : <br /> ^ �l <br /> ? do z <br /> J� �1ZEWEiz i RDn p <br /> I C3£it inly I x I O�� <br /> l <br /> 02 <br /> DEFARTMENT USE ONLY %%%(((�����/ / <br /> AOP11eN1en Acaroted RY �4 W` - <br /> D.I. I / i vi w, 9�� <br /> Grein lrwPactbn BY 1 D.b pymP Impxtlen BY DN.L.AL <br /> D,.Intlien In.Pavllen Br <br /> // J J / °•'• NOV 1 7 2000 <br /> � J ORy C'CIGICYI <br /> IC HE4�TFI SERVICES <br /> ENVIRON - - <br /> ACCOUHTINO ONLY: AID# FRCP <br /> PE coon FEE INFO AMOUNTREMITTED CHECK#/ SH RECEIVED BY DATE PE ITISMWCE REQUEST NUMBER INVOICE <br /> 'L ISO /t <br /> Pub.Health So".-Enviro.173(1/97) <br />