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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 95201-388 <br /> (209) 4683420 <br /> 541 — -75"( L <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION IS HERE BY RADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR:DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WON S. <br /> JOAQUIN COUNTY DEVELOPMENT TIME.CHAPTERS-1 115.3 AND THE ANDARDS OF SAN JOA UIN COUNTY PUBLIC H ALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> /O .S <br /> Al _ 12 1 N >� <br /> JOB ADDRE89R APNI � /4 f 1 �S�f- // clry Is/p G Ati PARCEL SIZE/AMI <br /> OWNER'S NAMED h/.(C - AODRESB�SO Z SC>,, /gyp/ PHONE .2 <br /> CONTRACTOR PC I�/ (SCC �.- Vl T ADDRESS UCA/'L i O Z" RHONE CrZ2 -/,C G <br /> SUB CONTRACTORfff I�I ADDRESS (ICI RHONE I <br /> TYPE OF WEM/PIIMP; ❑ NEW WELL URRERACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> ❑Nv ❑FWvalr H.P. DEPTH PUMP SET T. FIRST WATER LEVEL <br /> TYPE OF MMPI <br /> 1:1 OUT-OF 6ERV/I'CE WELL ❑ GEOPHYSICAL WELL I 11 BOIL BORING <br /> 9DESTRUCTION: Old arttt/ -& AQ 42 <br /> O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 11INDUSTRIAL .�(T❑��OPEN BOTTOM DIA.OF WELL EXCAVATION ((((T/��T� DIA.OF CONDUCTOR CASINO� I <br /> 11DOMEBTIC/PRVATE R7_1JMAVEL PACK/SIZE rvPL OF CA61NGI6TEEl/PVC DIA.OF WELL CASINO (rJ ` (� <br /> ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL �/ t SPECIFICATION \ 1 <br /> IRRIGATION/AG El OTHER GROAT SEAL INSTALLED BY /j'[Cje_ / ({ GROUT BRAND NAME w. H <br /> ❑ MONITORING GROUT SEAL PVMPFD' ON. CONCRETE PEDESTAL By PULLER:❑Yr <br /> APPROX.DEPTH � 1-7&'9-0'\ <br /> _ / LOCKING CHER BOX/STOVE PIPEC <br /> PROPOSED CONSTRLICTION/ORWNG METHOD: MUD ROTARY IX AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,ANO RU <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF TINE WORK FOR <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'e COMPENSATION LAWS OF CALIFORNIA.' COWMCTOR'S HIRNG OR BVB-COWMCTINO SIGNATURE CE <br /> THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAW <br /> CALIFORNIA." THE APPLICANT MUST CAM <br /> 244 HOURS IN ADVANCE FOR ALL REQUIRED I1 /�lN�SKCTON>S AT 12001 4NJ4]]. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> n <br /> 81' X ( � (.1'�Lact_=irJ� TRI. 1J LA D.I. <br /> RAT PIAN IDrp to Sv.I.I S Is to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPLITY. - 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPLPIY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> G. DIMENSIONED OWUNFS AND LOCATION OF ALL E%IUINC AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIp6,DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> �areJ�R�� LIL" <br /> e <br /> L Zb/ 2 p49 <br /> -AQ /"""3 <br /> `( <br /> pAy\' <br /> OMF-NT <br /> ' 6���EC�w`�'ED <br /> UG 1 8 1997 <br /> A <br /> JO <br /> Go Urt" I <br /> SAID SALT ERVICES <br /> P IBL'C EALTH S TH NIVISI(' <br /> ENVIt <br /> DEPARTMENT USE ONLY (dY 'may <br /> Appllv.non Aeerretl BY—_ ��/.� Yr./—W7j D.ta_ 4E—�� • I Orr <br /> Grow Irnpootlon BY I�.CL MCI,/y1 LEI C/ L" D.,-*40 <br /> e !J J ibmp In.P otlon BY DN. <br /> OmtrMtIon imp.PGPn BY <br /> 1 D.t. <br /> Comm.nt. j% IL �, - ,! ( ( 11Is <br /> C LL A <br /> l k� _ 4 r��4 <br /> AC C GLINTING ONLY: ,j AID( FACT CPJZv -34-t�' <br /> PE CODES FEE INFO AMOUNT REMITTED He <br /> EC I/CAH RECEIVED By DATE PORMIT/SEFIVICE REQUEST NUMBER INVOICE <br /> 3 b�. lff LID <br /> 2-�eCfJlhrJOlSe:, .?- sr19, M t At,, k (-4: f ti a,: 0, .ru, , <br />