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APPLICA7.10N FOR WIrLUFUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> F ENVIRONMENTAL HEALTH DIVISION <br /> E <br /> 304 EAST WEBER AVENUE. STOCKTON, CA 95202 <br /> (209) -3420 <br /> MOR-REFUNDABLE PERMIT EXPIRES t YEAR FROM RATE ISSUED <br /> (campIclte in TripItc®tot <br /> 11 APPLICATION 09 REFI BY MADE TO THE SAN JOAOUFN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIED.THIS APPLICATION IS?RADE SH COMPLIANCE WTf H SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1 115/.3^No THE STANDARDS OF SAI!JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> Lam" JOB AODRES81011 APNCd`SrI"rI CITY �� i J PARCEL SIYEJAPNO <br /> y <br /> OWNER'S NAM£ ` [ all <br /> Ia -�J ice `-. ADOPES® Z, `i. PHONE Ryl: I 4-J <br /> CONTRACTOR '; t j� �''. t�...s',`�-.. JV d'•� J!"} -�� 111<_�:/hlDbEiE Ba '`LA� _;y Uco PHONE N33 ('r-� !__ <br /> I <br /> Cusco ' 1.di ' ,r��J. r AbbREBffi LICA PHONE iE <br /> I f � <br /> } � TYPE OF WELLlPUMP: SCJ�+NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL f 11❑--11 OTHER <br /> { �❑ INSTALLATION ❑ WELL SYSTEM REPAIR ® CROSS—CONNECT AFFAIR l3 VAPOR EXTRACTION WELL a ,/ <br /> A New❑Relydr M.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> +4 RYPE OF PUMPI --- <br /> ! ❑ <br /> OUT-OF-SERVICE WELL ❑ OEOPHY6ICAL WELL A ❑ 601!BORING g <br />{ <br /> ❑DESTRUCTION: <br /> INTENDED UOE TYPE OF WELL CONSTRUCTIOq SPECIFUCATION& A <br /> 1 k ❑ INDUSTRIAL ❑OPEN got—tom DIA.OF WELL EXCAVATION !q DIA,of CONDUCTOR CASINO D <br /> OOMESTIC/MVATE RAVEL PACK1912E TYPE OF CASING/STEELIPVC CV4 DIA.OF WELL CASINO O <br /> M1 [F I ❑ PUSUCMMUNMWAL DRIVEN DEPTH OF GROUT SEAL ~ C� SPECIFICATION q q <br /> L I IRRIOATIONIAO ❑OTHER GROUT SEAL WSTALLED BYC bR01fT BRAND NAME_' _"jy(;,J�`' __ E <br /> 11 ❑ MONITORING _ OAOUT SFAL PUMPEO�Yae (IN. CONCRETE PEDESTAL BY ORILLER:,,G; <br /> DEPTH /yo Yee ❑No S <br /> F <br /> _ LOCKING CHESTER BOXISTOVE PIPE f - 5 <br /> PROPOSED CONSTRUCTIONMbPSLL1N0 MIRti00: MUD NOTARY.- AIR ROTARY AUGER CABLE OTHER <br /> I HE'WRY CERTIFY THAT I I4AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE W"SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AOEMT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE MAK FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COIRPFROAT/ON LAWS OF CALtFOPINIA.' CONTRACTOR'S FGRINO OR SUB-CONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMfT IS 16SUE0,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'O COMPENSATION LAWS OF <br /> CALIFORNIA.' THE CANT�pM/U�_TT�CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INOPEC"ONS AT 120CI 4611-M22, COMPLETE DRAWING AT LOWER AREA PAV;ADED,,,!'] <br /> Sl9ned% _— _.,._ TIN@ �.,s.//1. - beta -� I. j <br /> F PLOT FLAN(Drew to Sadei Saolo •fe <br /> I 1. NAMED OF OTMET6 OR ROAD$NEAREST TO OR BOUNDING THE PROPERTY. 0. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PRDPERTY,OMINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOOAL SYSTEMS. <br /> 9. DIMENSIONED OUTLINES AND LOCATION OF ALL EX1SrWM AND PROPDSEO S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS bIaVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> I <br /> Fi - - <br /> F1 <br /> P' <br />