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`.,. APPLICATION FOR WELLIPUMP PERMIih <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201388 <br /> (209( 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompl{b in TFipls{U) <br /> APPLICATION IS HERE BV MADE TO THE SAN JOADUM COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPIIANCE WITH BAN <br /> JOAOVIN COUNTY DEVELOPMENT TITU,CHAPTER 9-1115 3 AND THE^TANDARDS OF SAN JOAQUIN COUNTY PUBLICM <br /> /HEALTH SERVICES.ENVIRONMENTAL HEALTH DSKIN, <br /> JOB ADDRESSMR APR# C-nl�� ✓R C"'g7!s��e 99L�0 ETA,`/ PARCEL BIZ/VAPN{ <br /> OWNER'S NAME <br /> „� <br /> COWRACTOR_M—,t .L 1tS I>PII /I1 LIQ' ADDRESS_/ / NC <br /> UICPRONE <br /> SUB CONTRACTOR ���y// ADDRESS �p PONE 0 <br /> TYPE OF WELL/PUMP: P�<M WELL ❑ REPLACEMENT WELL ElMONITORING WELL/ ❑ OTHER <br /> •/❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAMFl EXTRACTION WELL I , <br /> TYPE OF PUMPS ❑NeW❑ M.P. DEPTH PUMP SET FT, FIRST WATER LEVEL G r. <br /> ❑ OUT-OF-SERVOE WELL ❑ GEOPHYSICAL WELL' ❑ BOIL BONNO B <br /> ❑DESTRUCTION: L <br /> INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATION{ <br /> A <br /> ❑ <br /> INDUSTRIAL 11 OPEN BOTTOM DIA.Of WELL EXCAVATION DIA.OF CONDUCTOR CARING D <br /> ❑ DOMESTIC/PPI ..�C <br /> VATE Jav1AVEL PACK/SIZE TYPE OF CASINGISTEEL/WC CIA,OF WELL CASING �� D <br /> ❑ RIBLIC/MUNICIPAL 11DRIVEN DEPTH OF GROUT SEAL Ha I SPECIFICATION A <br /> 'DIRIGATION/AG ❑OTHER �'yj GROUT SEAL INSTALLED BV GROUT BRAND NAME E <br /> ❑ MONITORING �2_� I• J'zE0U SEAL PUMPED:�Vr [IN. CONCRETE PEDESTAL BY PH LLFIE❑YYesry[';Apro S _ <br /> APP ROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> Y. <br /> PROPOSED CONSTRIX:TIONRNOWNQ METHOD: MUD ROTARY AIR ROTARY AUGER CARIE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO TNAT THE WON(WILL BE GONE IN ACCORDANCE WITH SAN JOADUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT-8 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERPONAANCE OF THE WON(MR"OM <br /> IT <br /> THIS PERMIS ISSUED.I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBOOIETRACTING SIGNATURE CERTWIE6 <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(EOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMP4FISATION LAWS OF <br /> CMIFORNIA.' T APPLICANT MWT CALL 24 HOUR{IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120)468 423. COMPLETE DRAWING AT LOWER AREA PROVIDED, <br /> R <br /> 5".x L 1 C. ( b'1 /L ALFA{'n�j Tln. � i'L 1/00 <br /> PLOT PLAAI IDl—1.S .I Scale <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE POPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OWUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 5. 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 /> \ ` <br /> AUG 2 2 195; <br /> AN ) <br /> �E` IL �'AIgr'tIr'�FT�d. 1 <br /> DEPARTMENT USE ONLY <br /> Apgk.Rbn A=WIW BB\y('/p \ J3.tY"'� L,L,--z. DeR. <br /> Gl.m ERP.11—BY \b ll !A/T)1niCP/A—/ D.m 1_!r,9 t Pumo I�omcRnn Br ons �V� <br /> DSIruPtbn In.P./ef/e�n Br q /'/� D.R. <br /> Commenu: ] L� IO LV.�AM <br /> J <br /> ACCOUNTING ONLY: AID' FAC, <br /> PE CODES FEE INFO AMOUNT RNATTED HECK MASH M(;BVED SY GATE PFA.IITMEHVICE REQUEST NWOM INVOICE <br /> a q r� <br />