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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. 13OX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> 12091 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplot$ In Trip&$t$1 <br /> APPLICATION IS AERIE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE V40W DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE YVI[fN SAN <br /> JOAQUIN COUNTY DEVELOPMENT TIRE,CHAPTER 8-1115.3 ANuAm STANDARDS OF SAN"AMIN COUNTY HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> J , �(..I� J w.eL,ty <br /> JOB ADdE88IOR APIN �V �CA -Q tic/ 3�C-r CET�TY�///�✓I / / PARCEL SREMNI S-31 - O�+yJZ <br /> OWNER'S NAME/o�1 fff /1/ ADOPE88 1�O/.('J�a[lJ/r17C1 yl.�!(_C�intl` ` PRIONS t . I <br /> CONTRACTOR)//t/I �f /J�a�s/'in�[ L I N ri ADDRESS / L M P�13.PLNS l'fi IA�.D6�� FHONE 9-522 LA" <br /> GUS CONTRACTOR !!gy�pp ����,✓ ADDRESS mo PRONE/ <br /> TYPE OF WELLJPUMP. ❑ NEW WELL ,Jo.nEPLACE NT WELL ❑ MONITORING WELL i ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SY TEM REPAIR ❑ CROSSCONNECT REPNR ❑ VAPOR EXTRACTION WELL E J <br /> ❑NP ❑R"Pok H.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL O <br /> -^ <br /> TYPE OF PUNT% <br /> ❑ OUT BERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING B <br /> 1 1 _ <br /> ❑DESTRUCTION: L IIA- '�l✓� 1^ Q: <br /> INTENDED ME TYPE OF WELL CONSTRUCTION SPECIFICATION$ A <br /> r/ <br /> ❑ INDUSTRIAL ❑F�OPEN BOTTOM DM.OF WELL EXCAVATION ��/ DIA.OF CONDUCTOR CASING D <br /> 00-wOMESTICRTVVATE COARAVEL PACK/SOE TYPE OF CASINGAETEEUPVC DIA.OF WELL CASING 61 " D <br /> ❑ RIBLIC/MUNICIPAL ❑MWN w' DEPTH OF GROUT SEAL / SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER G.0 l ,J- py GREW BEN.INSTALLED BY GROUT BRAND NAME f O` £ <br /> MONITORING <br /> APOROX.DEPTH �7 - GREW6FALLOCKING PUMPED: <br /> C�ERSOON. <br /> XAETOVE PEE CONCRETE PEDESTALSRLLEIE❑V. S- <br /> RROPOSED CONSTRUCTIONIDRWNO MEEHOO: MVD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN"AMIN COUNTY ORDINANCES.STATE LAWS,AND RULES ANO <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENE'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT N THE PERFOMIANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUBCONTAACTNG BKJNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOMIGMAN'$COMPENSATION LAWS OF <br /> CAUFORNIA- APPLICANT APPC�A/N� W <br /> T MT CALL 24 HOURS N ADVANCE FOR ALL REQUIRED INSPECTIONSAT110DRAWING AT 4p�421. COMPLETE DRAWAT LOWER NEED <br /> A PROVID . <br /> 61$ntl X_ LTL_• � ✓� L(.H1" TItle N N N N/tT_Lti 270 /)67 <br /> PLOT PUN E.Pw to 6u1e1 Sole 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF MUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIWNO DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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 /> ✓v <br /> 1 / <br /> f JUN 2 4:1996 <br /> SAN 'OAQ(11N{;uUutY <br />