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i <br /> APPLICATION FOR WE111PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 988,904 EAST WEBER AVENUE,STOCMN,CA 95201388 <br /> (209)468.3420 <br /> N0111•11EFUNDASLE PERW7 EXPIRES NEAR FROM DATE ISSUED <br /> r,w*IBtB IR Tr+REB1B) <br /> APPLICATION IE HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR W NISTALL THE OM DESCRIBED-THIS APPLICATION IS MADE M COMPLIANCE INTTH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUW COUNTY PUBLIC H ALTH SERVICES,ENVSIONMENFAL HEALTH DPASION. <br /> /,/� 4th <br /> JOB AD0AE9S j'!2&0 CrTY CGL PARCEL BQFJA/M',Y 7f�Q `/ <br /> OWNER'*NAME 1 YL�_I AOOREas // WfAN PF:OIrt!(JC`�`['�JOt7 <br /> coNrllACTon h l I ADOAEsljf�1 /Q� fl!J_ uc46 `PHONE r��2 QL'd <br /> SUS CONTRACTOR ADDRESS LIC/ PHONE <br /> TYPE OF WELL/PUMP; 4Z-WW WELL ❑REPLACEMENT WELL ❑MONITORING WELLf ❑OTHER_ <br /> ❑INSTAUATIGN ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑ VAPOR EXrAACTION WELL! <br /> 11N..❑P Ir H.P. DEPTH PUMP SET_FT. � .I/ F N WATER LEVEL O <br /> it (TYPE OF PV MPI J M [[��I� /�� <br /> ❑OUT-OF-BERVICE WELL ❑OEOPHYSICAL WELL• IL BOISMO 2 CTA� B <br /> ❑DESTR UCTION, F I�' <br /> `iLJf�iJ- <br /> IN Y►L COM411AWTION! IFICARO A <br /> I�INDUSTRIAL ,�❑O"PEN BOTTOM DIA.OF WELL EXCAVATION OM.OF CONDUCTOR CAGING <br /> py <br /> �L7�hEIT CRRIVATE '-B QjMVEI PAC I.- TYPE OF CASINWSTEEL/ ULK <br /> D .OF LL CASINO ( DO <br /> ❑PUSUCMAUNCIPAL [3 DRIVEN DEPTH OF GROUT SEAL _Y _ SPECIFICATION R O <br /> ❑ IRPIGATIOHIAG ❑OTHER GROUT SEAL INSTALLEOO BY ( GROUT BRAND NAME E C <br /> ❑MONITOWNG 1 GROUT SEAL PUMPEDUEiYr ❑N. CONCRETE PEDESTAL BY LIM'❑Y- <br /> APP110 x.OF/TH_ LDCKWO CNERER SOXISTOVE PIPE g <br /> T 3 HIOPOSM COMA TINGT)Offlm IWNO METHOD-MUD ROTARY A!R ROTARY AtWR CASLF OTP*F <br /> ` a <br /> I W-EBY CERTIFY THAT I HAVE PREPARCO THIS APPLICATION AND TIIAT THE WORK MALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AJAYT <br /> RFOULATIONS OF THE SAN JOAOLAN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CEFITTFRES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE W'OW FOR <br /> 7618 PERMITIBIBSUED,I SHALL NOT EMPLOY PERSONS 9LTNJECT TO WOOIDAAN'!COMPUNATION LAWS OF CNJFOPEBA.' CONTRACTOR'S WISNG OR RV"ONTRACTING SMATUrE CERTIFIES <br /> THE FOLLOWIIIO: '1 CERTIFY THAT IN THE PERPORMANCE OF THE WORN FOR WIRCH THIS PERAST IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOrAMAN'S COMP9/BATIDN LAWS O <br /> CALIFORNIA.' TK APPLICANT M�LUS-T`C(ALLLOH HOURS IN ADVANCE FOR ALL RIIOUIRSD INBP6T10(/ Ai 12011411AA22,COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> SROM TIII• i- <br /> 107 <br /> O-G <br /> PLOT PLAN CO—Ie 6e 4 6u1. le <br /> t.NAMES OF STREETS OR ROADS NEAPEST TO OR HOUNDING THE PROPERTY. a. LDCATTON or HOUSE SEWAGE DISPOSAL SYSTEM 011 PIO/OBETT <br /> 2.CUTLSE OF THE PROPERTY,810"DIMNS <br /> DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTWRFS AND LOCATION OF ALL EXISTB16 AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED.REAS BUCH At PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPER"OR ADJOIMNO PROPERTY.[Fi <br /> f <br /> I <br /> ............. <br /> S <br /> DEPANTMVIT USE ONLY mak✓ �T/ /{' <br /> APPllc.rbn A—p—By_ �;! n 4 D.ts/p� <br /> Or.ul Ir.Pacnen SY �, f 0.1. I`'I`t!~"fL�i.P I.,.peerbn By D.1. <br /> d.n.ntbn Irsesotbn B__r <br /> Cemms,n:�yGLyTt NI I 1 IVO Q11�IT yI, S ' <br /> Dvl -MA(-sW1M j-L -o G✓rdrfi oh Kt*:� � L✓Vhi t✓ 1�. <br /> ACCOr�EL 71N0 DNL T: Alw I FACE <br /> PEI CODES i <br /> [ <br /> IF `� P� UO INFOAµ}g�UNT �OTT TTEDCH�IfJ ABH RKBVED ST DAT[ ►FN�Si Qo.3�50 5'O .oo 6I s R�-o� >7 9 � p3-- <br />