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APPLICATION FOR INELLIPUMP PERMIT /L/ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA%Ml-358 <br /> 12091489-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> ICampleta IS TTlpRl:atal <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOWN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WON(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WHO/SAN <br /> JOAOUNI COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115 AND THE STANDARD OF SAN JOAOUIN COUNTY MOLIC HEALTH SERVICEG.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORESSIOfl APNF D `&��h� f t C 0. U f] , P PARCEL BQPAPNT <br /> OWNER'S NAME D eo C-S ADDRESS I01 SOLLI YL IR/vG�.7E�� `I Pp`pNE♦ <br /> CONTRACTOR ADDRESS ao a0Y 1 �.1 1 UC/� 4-mMEF 466- <br /> CONTRACTOR <br /> SUB CONTRACTOR ADDRESS LTCE PHONE <br /> TYPEOF WELI/PUMP: ❑ NEW WELL ❑ REPACEMERT IVELL ❑ MONITORING WELL E ❑ OTHER <br /> 11INSTALLATION 1:1WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR 1-1VAPOR"FRACTION WELL F J \ <br /> S L,_6 ❑New❑R w, M.P. OEM"RUMP BETFT. FIRST WATEfl LEVEL <br /> D <br /> RYPE OF PUMPI <br /> ' ❑ OUT-0E-SEIVVVICE WELL (❑ GEOPHYSICAL WELL E ❑ SOIL BOEING R <br /> L.e— <br /> 1 TENDED USE TYPE OF WELL -tONSTRVCTI 11 SPECIFICATIONS A <br /> ❑� I/NgY51"NAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION IRA.OF CONDUCTOR CASINO p <br /> LJ DOMESTICMOVATE ❑GRAVEL PACKMIZE TYPE OF CASINOISTEELIPVC VIA.OF WELL CASINO p� <br /> ❑ PUBUCIMUNICIPAL Ll mw" DEPTH OF GROUT SEAL SPECIFICATION R <br /> INSIGA <br /> MONN <br /> ClMMT RN ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ OEING GROUT SEAL PUMPED:❑Yw ❑Ns CONCRETE PEDESTAL BY ONLLER:❑Vw ❑NP S <br /> APPROX.DEPTH LOCKING CHESTER BOXUSTOVE PIPE S <br /> PROPOSED CON/TRUCTIONIgMHINO METHOD: MUD IIOTARV AIR ROTARY AUGER CABLE OTHER <br /> 1 HEEI'BY CENTIFY TN PAVE PRE RED THIS APRJCATION AND THAT THE WOW.WILL BE DONE IN ACCOR5ANCE WITH SAN JOAQUIN COUNTY OADINANCES.STATE LAMS,AND RULES AND/\ \ <br /> REGULATIONS OF SAN"AMIN UNTY. HOME OWNER OR LIC SED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF TNM MM FOR WINCH <br /> THIS PERMIT IS ISSUED,I MALL NoTffiJIPLOY PERSONS SUBJECT 36 WORKMAN'S COMPSAMATIOR LAWS OF CAUFOMBA,- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES[��I <br /> TILE FOLLOVJI : .ICE IFY T THE PE ORM F 1aL FOR WHICH T PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAMa COMPENSATION LAWS OF \ <br /> + CALIFORNIA.' THE M CALL NO FOO TIIIw EO 1 TIONG y12001408J =. COMPLETE DRAWING AT LOWER AMA PROVIDED. <br /> SI.—,X -0001 D.I. <br /> not PLAN(Draw,le Seale)eetl• 'Le <br /> - <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR p,,MSED <br /> 2. OUTLINE OF THE PIOPERTY,DIVING DIMENSIONS AMD NORTH DIRECTION, EXPANSION OF$MADE DISPOSAIL SYSTEMS. <br /> 2_ DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTINO AND PROPOSED S. LOCATION OF WELLS WTTIIIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,OMVEWAYS,AND WAUt6. ON THE PMOPERTY OR AD.IOINING PROPERTY. <br /> S . <br /> �Q.ST L:cJ Erm o�i �U• <br /> ILoft's . fh Rel d 2d ' <br /> 1 <br />