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o z�sz��o <br /> APPLICATION FOR VVELLIPUMP PERMIT _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> RO, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209( 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRBM DATE ISSUED <br /> IComplBu In TAI <br /> APPLICATION 19 HITE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WOR(DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TOLE.CHAPTER 9 1115.13 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORE68/OR AP/N/I I3 I / F' YIT ' ,n F CITY Y1 L PARCEL SIZE/AFNI <br /> OWNER'S NAME Inr f�/.�! n fy�r.�f�rin ApOREBP_ L✓­1/,•,�[2/n I 6 RIONEI�35- a �63 <br /> CONTRACTOR_-r G• I �S_5 ��, ,_ J._M[� ADDRESS rF/ {J��CI(n �' fr EJGFy'_ 446.1 PHONE I _oz��L <br /> PUB CONTRACTOR Y <br /> ADOREBP UCI PHONE <br /> TYPE OF WELL/PUMP. ❑ NFW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> c I, /1/T ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> ❑New❑Repelr H.P. DEPTH AIME 56-FT. FIRST WATER LEVEL p <br /> n VPE OF PUMFI 21+.O I fi C,e mne-,y, - <br /> E� _Y ❑ OUT OF SERVICE WELL ❑ OEOPHYSICAL WI ❑ SOIL BORING q \ <br /> 1:1 DESTRUCTION- ELL _l <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS d <br /> ❑ IND AL ❑OMNBOTTOM CIA.OF WELL EXCAVATION CIA.OF CONDUCTOR CASING D <br /> DOMEPTWII`RIVATE GRAVEL PACK/BRE TYPE OF CASING/STEELJPVC p1A.Of WELL CASING p <br /> ❑ R/BLICIMUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION q <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F <br /> ❑ MONITORING GROUT PEAL PUMPED: ❑Ys ❑No CONCRETE PEDESTAL SY DRILLER:❑Y.e []No 5 <br /> APPROX.DEPTH LOCKING CHESTED BOX/STOVE RPE S M <br /> PROPOSED CONSTRVCNONRHBLLING METHOD: MUD ROTARY AIR ROTARY AUGEfl CABLE OTHER <br /> - <br /> I HEREBY CERTIFY THAT I HAVE PREPAREO THIS APPLICATION AND TIIAT THE WOW WILL BE DONE IN ACCOPAANCF WITN BAN JOAOUIN COUNTY OMINANCES,STATE LAWS.AND RULER AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PEOMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUD CONTRACTING SIGNATURE CERTIFIES <br /> THF FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY MASONS SUBJECT TO WORKMAN'S COMPENSATION"We OF <br /> CALIFORNIA,' T,11F AF�CANT MUST CALL 2A� CE FOR ALL.REQUIRED Ij T�14722. COMPLETE DRAWING AT LOWER AREA PIOVIDEM / / <br /> elon.e x (')/may w`.1.�/LJ�' <br /> Till. O� pa. 3 <br /> POT PLAN IDr.w to PeJel Bn.l. to <br /> 1, NAMED OF STREETS OR ROADS NEAREST TO On BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE UIBPOBAI SYSTEM On PROPOSED <br /> 2, OULLINE OF THE PROPERTY.OMNO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWARE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED ONTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED D. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. ON THE PIOMRTY On ADJOINING PROPERTY. <br /> [ � Banc ho <br /> -+c 2 <br /> o <br /> d � <br /> V <br /> —orb,�k <br /> �' Shoff <br /> iL <br /> DEPARTMENT USE ONLY <br /> _ _..r- --ass r _la" (/'� �/ )))))) <br /> 7,pPllentlen `eepled DI _ \ ��" '�L� D.re l Are. <br /> G•eut l.•,Peerbn PY � PurnP ln.PeellenB O.r. 5-5-57 <br /> De.baSen Iwnecrlen BY Dee <br /> C.m o.: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED -EHECKI ABH RECEIVED BY DATE PERNIRTISERVICE REOVES LAUNDER INVOICE <br /> 0`S D S0 3 a1 6236 a.Sn <br /> Pub.Health Serv.-Enviro.173(3/96) <br />