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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 4883420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> S Trolicals) <br /> APPLICATION N Y M BY MADE TO THE BAN JOACHAPTER <br /> UIN9-1 COUNTY FOR A PERMIT TO CONSTTRUCTI ANDMn INSTALL THE WOR(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WHH SAN <br /> JOApVIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1 115.3 AND THE 6TANDARpe OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AMMSSMA APNI—/005S lqe�ry R� CIT! G ce, L <br /> PARCEL <br /> RCEL 9NEIgA!• <br /> R'S <br /> OWNENAME l— ('T{n^1 y�! R O'er/�F S ADORERS_ r4 In, <br /> PHONE I <br /> CONTRACTOR_ Y`0-11. . f^J2 /' �hC nopnEBeF(/LyJ�(f� Bgy)�G LICp'�53�.JaRPOUE• —o2�'jl/ <br /> BUS CONTMCTOR <br /> ADpREeB UG <br /> RHONE F <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL• ❑ OTHER <br /> El IN"ALUTIoN 11 WELL SYSTEM REPAIR 11CRO99 CONNECT REPAIR Cl VAPOR E%TRACTION WELL I Lvb 12 Nwv❑Repelr ILP rl;_ DEPTH NMP SET R. FIRST WATER LFVEI <br /> RYR OF PUMP) G <br /> ❑ <br /> ❑DEBTINICiION: OUT OF SERVICE WELL ❑ GEOPHYSICAL WELL• ❑ BOIL BORING <br /> R <br /> INTENDED use TYPE OF WELL CONSTRUC LION SI'll Curl CAIIONS I ) <br /> ❑ INo RAI. ❑OPEN BOTTOM A f4V1/ <br /> rU—d.'/ OW WELL EXCAVATION DIA.OF CON�UCTORCAARIO D �� /r�� <br /> OOMESTICAINVATE ❑GRAVEL PACK/9DE_ TYPF OF CASINO/STEELIPVC DIA,OF WELL CASINO LJI <br /> ❑ fVBIICRSUNICIPAL ❑pnIVEN DEPTH OF GROW SEAL SPECIFICATION O U) <br /> R <br /> IRROATIONIM El OTHER GROUT:FAL INSTALLED BY GROUT BRAND NAME_ <br /> ❑ MONITORING E <br /> GROUT REAL RIMRD: ❑Yw [I Ng CONCRETE PEDESTAL BY pRILLEn:Ely- ❑Ne S <br /> APPROX.DEPT" LOCKING CHESTER BO%/STOVE RPE <br /> PROPOSED CONSTRUCTIONId1LUN0 METHOD: Moo I ITARy AIR ROTARY AUGER CABLE OTHER <br /> — <br /> 1 HEREBY CERTIFY THAT I HAW PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES <br /> A�P1��[[�� <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT M THE PERTORMANCE OF THE WORK FOR 4NIICIILV <br /> TIBS PERMIT 11 ISSUED,1 SIHALL NOT EMMOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S RIMING OR SUR CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF IME WORK FOR WHICH THIS PEnMN to ISSUED.1 SIPALL EMPLOY PERSONS SUBJECT TO WORIlMAN'e COMPENSATION LAWS GF. <br /> CALIFORNIA.' TLIF I1MICANT MUST CA 311bURe IN AnV�FOR ALL RFO111. IMS�DON�AS)A�Zp� MPLEIE OMWINO N LOWER AREA IYgNpEO. <br /> elEnrre% �•i/yd_py <br /> MOT RAN Irl.ew Ie Betel Beeln 'b <br /> L NAMES OF STREETS OR ROADS NEAREST TO OB BOVNDINO THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE OISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLDIE OF THE RIORRTY,GIVING DIMENSIONS AND NORTH DIRECTION. E%PANBION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL E%ISTINO AND PROPOSED S. LOCATION OF WELLS WITHIN RAOIVS OF ONE HUNOPNn rirry R. <br /> STRUCTURES,INCLUDING COVERED AREAS BUCH AS PATIOS,DRIVEWAYS,AND WAMS. ON THE PROPERTY OR ADJOINING RIORRTY, <br /> QodcA 7- <br /> LA LA <br /> o <br /> Hwy 1 zo <br /> Is <br /> DEPMTMMT USE ONLY 0370 <br /> B <br /> Appllcetlen Aeeepl, BY <br /> Grern Irwpecllen Y pate <br /> P,mp ImpwOen By <br /> Orwlnstbn Im Dele <br /> Pwllen AY <br /> D.I. <br /> Cmr.mo-e,: <br /> ACCOVHTING ONLY: AID• FACJ <br /> PE CODES FEE INFO AMOUNT REMITTED HIECYiMA914 RECEIVED BY DATE PIDMITMERVICE MOUEeT NUMBER INVOICE <br /> k 188 iaP-31R� D <br /> Pub.Health SAN.-Enviro.173(3196) <br />