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APPLICATION FOR WELLIPUMP PER.— <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 3B8, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICompMto In TEIpIicEtel <br /> APPLICATION I6 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WRTH SAI <br /> JOAQUIN COUNTY DEVELOPMENT TRATE,CHAP/TEAR�9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSMR APNIE 1 ✓)� i-ky(e✓I I x I CITY <br /> �cS(tel�(T�j• J � / PARCEL SIZE/APNI <br /> OWNER'S NAME Pe VAVVV //-YL C``A-✓✓//1/L/C'� ADDRESS/;?J2// Q,AJ}/ J`JTC�'gI,(/��j}jL�` PHONE F <br /> CONTRACTOR /� ` \� Uf�ll�llka _FTC! ADDRESS// �41&W ReC� UCOELfX2.Z_PHONE Z—L <br /> SUB CONTRACTOR �y ADDRESS UCI PHONE# <br /> TYPE OF WELL/PUMP: IYIJ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> V❑INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> ❑N.❑Rep.11 M.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> TYPE OF PUMP) <br /> ❑ OUT-OF 6ERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑yOPEN BOTTOM DIA.OF WELL EXCAVATION !�I, DIA.Of CONDUCTOR CASING <br /> N <br /> ❑ DOMESTICIP ATE 0.AAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC nP vc DIA.OF WELL CASING �� `l <br /> ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROAT SEAL ,}V/n SPECIFICATION <br /> �INSGATION/AG ❑OTHER GROUT SEAL INSTALLED BY _ µK[.I LI( GROUT BRAND NAME (Q <br /> ❑ MONITORING ,f)( GROUT SEAL PUMPEDOElY. [IN, CONCRETE PEDESTAL BY LL <br /> MER:❑Y. Ja <br /> APPROX. D1JTH �B� LOCKING CHESTER BOX/STOVE RPE <br /> PROPOSED CONSTRULTIONIDIEWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES ANE <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORE(FOR WHICH <br /> THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR 81)"ONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS BVSJECT TO WORKMAN'S COMPENSATION LAWS 01 <br /> CALIFORNIA.' TN APPl1CANT MUST CALL 2A HOUR{IN ADVANCE FOR ALL REQUIRED 1 SPECTWNS AT(2"1 AA 23. COMPLETE OMWING AT LOWER AREA PROVIDED. <br /> ^ <br /> 61Prod% ( ( (.. W/�I PLY TILIs N 1�/1C o V.I. <br /> PLOT MAN ID,.w I.fiatlel S—E. Ie —/ <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TIIE PROPERTY. #. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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 /> wet( <br /> r s�� <br /> n <br /> blob,� <br /> JYMRECEIVED ENTT <br /> JUL 181997 <br /> SANJOAQUIN COUNTY II <br /> 11161 Jr.HEALTH SERVICES <br /> ENVIRONMENIAL <br /> DEPARTMENT USE ONLY <br /> AVPllc.tlen Accagled By <br /> D.I. Ms. [X <br /> c,em ImPe<uen BY <br /> P PePeeR ey D.IS <br /> Davw6en Io.P VP er <br /> CPmmmu: 11y <br /> ACCOUNTING ONLY: AID# FAC/ <br /> rP/F COOED FEEINFO AMOUNT REMITTED CHECK/I ASH RECDVED BY DATE PEHMITISERVICE REQUEST NUMBER INVOICE <br /> t 3 jo O TI - 7 OLFOqS? <br />