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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ` ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NOW-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete M TrIpR9etol <br /> AF IMATION 09 HERE SY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR WSTALL THE WOR(DESCPBED.TIDE AFFIMATON IS MADE M COMPUANCE MH SAN <br /> JOAOVIN COUNTY DEVELOPMENT TTn�1E],CHAC�FER 8-11/116.]�/()�F�lp,T/HE BT OF BAN"AWN COUNTY PUBLIC HEALTH SERVICES.ENVNIOHMENTAL HEALTH ENVISION. <br /> r JOB A SSMR"we 'I7 / J�(T/Y /�C//1 J�-V ' CITY PARCEL 991lMA NE (R j3/—32c) <br /> -2L) <br /> OWNER'S NAME OO(IYGf AOOIEBt /Z/E� LI���T; ��V/ PwfaF 7IS'- OSIJ <br /> CONTRACTOR DV'F WT AOOFESB Me I'MEF <br /> SUB MWAACTOR AGGRESS me PRIME# <br /> TYPE OF WELUPUMP: ❑ HEW WELL ❑ REPtACEMEHT WETL ❑ MONRORNM WELL I ❑OTHER <br /> Te p / ❑ NSTAUTION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> F UING ❑NAw❑WPM H P DEPTH PUMP$I _". FIRST WATER LEVEL O <br /> nvP of PUMP <br /> _ OIR-0E-SERVICE WEtt El GEOPHYSICAL WEU I ❑ 909.NORMO 8 <br /> ❑DESTRUCTION- <br /> INTENDED USE TYPE OF WELL CONSTAUCTON BFECIPCATIONG ✓1 T� A <br /> ❑ INOUSTPA ❑OPEN BOTTOM OUL OF WELL EXCAVATION In GIA.OF CONOVCTOR CAMM p <br /> ❑ WMESTWMFIVATE 11 GRAVEL PACK F TYPE OF CAGAMSTIEELANC DIA.OF WELL CASINO p <br /> ❑ PURICAUUNOIPAL ❑PMN DEPTH OF GAIRIT SEAL SPECIFICATION R <br /> RYYpATONIAO ❑OTHER GROUT SEK NSfAL1E0 I Y GMUT GRAND NAME F <br /> MONHOPHO ��y � GROUT SEK IIMPEO: ❑Y. OwCONCRETEPITHSTA SYDPLLER:❑Yr ❑Ne 5 <br /> APPROX-DEPTH L4Ak A+W• LOCKING CII "M Box WS oVE RPE S <br /> PROPOSED COMSTRUOIroNIDNlI1NG MENIOD: MVO ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I IIE9EBY CFFU IF/THAT I HAVE PREPARED TINS APPUCATMN AND THAT THE WORK WRL BE DONE M ACCOMAICE WITH SAN JOAUUN COUNTY ORDINANCES,STATE"We.ANO RULES ANO <br /> REO TIONS OF INS SAN"AWN COUHtY. HOME OWNER OR LICENSED AOEN T'S SIGNATURE CERTIFIES THE FOLLOWNO:'R CERTIFY THAT M THE PERFORMANCE OF THE W W FOR WMCH <br /> TMS PERMIT 19 TSBtRO,I BNAXX HOT EMPLOY PERSONS SUBJECT TO WOROAAN'S COMPENSATION I-A S OF CALIFORNIA.- CONTRACTOR'S HARM OR SMCON TRACTIM SIGNATURE CEMSTES <br /> THE FOLLOWING: -1 CERTIFYT N TLIE PERFORMANCE OF THE WORK FOR WNOH THIS PERMIT IS ISSUED.1 SHAL EMPLOY PERSONS SUSPECT TO YVOROAA-6 COMPENSATION tAM OF <br /> CAUFORMA.' THE APPIC MMT CALL N HOURS N ADVANCE FOR ALL REQUIRED INSPECTIONS AT PPWE <br /> OST 44*414n. COMPETE ORAMNO AT LO9 AREA PRO <br /> ss'+ X TNM 11Gr� V.. y <br /> ROT MN M.Pw Is IMAM SaAIFI. <br /> I. NAMES OF STREETS OR ROADS WA EST TO OR BOUNONO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE OIOFOM SYSTEM OR PROPOSED <br /> -. 2. OUTUNE OF THE PROPERTY.ORA1M DIMENSIONS ANO NORTH OIRECTON. EXPANSION of SEWAGE DISPOSAL SYSTEMS. <br /> f. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTNM AND P OMSEo S. LOCATION Of WELLS WITMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURFS.INCLUDING COVERED AREAS SUCH AS PATIOS.DPVEWAY9.AND WAXB. ON THE P OPERFY OR ADJOINING PROPERTY. <br /> k N <br /> NE%Y ENT <br /> Q APR 3,01998 <br /> cell <br /> c. G Av GES <br /> 2 S—�� .. IDS 1 _ ... _. F SiUtiAM1EFIdAL HEr1LTH DINfSIC1N... . <br /> 71 ti <br />