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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tripliatel <br /> APPIJCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPJCATION IS MADE IN COMPLJANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE, �ER '15�`D THE/v/pT�A BRADS OF S�AN JOAQUIN COUNTY PUBl1�C/H/(A_LTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDIRE88/Ofl APNN / Il .'t CITY Z: (/i/e PARCEL 812FIAPNN <br /> OWNER'S NAMEr.��T,� ADDRESS 0. PHONE# <br /> CONTRACTOR wt.a.( ,\ 1 /t c, ADDRES62 T//T &TT TT UCI 0 %HONE I C <br /> SUBCONTRACTOR ADDRESS LIC.' PHONE <br /> TYPE OF WELLRVMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR 13ElPO <br /> CROBS{ONNECT REPAIR VAR EXTRACTION WELL i J <br /> c <br /> LJ 13N. TAR.w H.P. fl-- DEPTH PUMP SETT. FIRST WATER LEVEL, / O <br /> (TYPE OF PUMP) <br /> 13OUT-0FBERVIOE WELL ❑ GEOPHYSICALWELL# ❑ SDK BORING S J <br /> ❑DESTRUCTION: t <br /> S <br /> INTENDED UEE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> y�0 <br /> e1 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O Z <br /> /c. DOMESTIC/PRIVATE 1:1 GRAVEL PACK/SIZE TYPE OF CASING/STEELT C DIA.OF WELL CASING O [ � <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R -I <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E F^ <br /> ❑ MONITORING T GROUT SEAL PUMPED: ❑Y« ❑No CONCRETE PEDESTAL BY DRLLFR:❑Y« [IN. SIC <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S G <br /> PROPOSED CONSTRUCTION/gtlLLNG METHOD: MUD ROTARY NR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERFIFY THAT I HAVE PREPARED THIS APPIJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> AEGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECTTG WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COWRRA OR'SHIRNOORSUB ONTRACTINGSIGNATURECERNFIES <br /> THE FOLLOWING: 'I CERTIFY TNAT IN THE PEflFORRMA CE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN_ <br /> C�FORNNTMUST C M 110 ADVANCE FOR ALL REQUIRED INE�P/EB/T1 4 AT I]0{I 4641 S=. COMPETE DRAWING AT LOWER AREA PROVIDED. <br /> SI M X /r Title / i Dete <br /> POT PAN IOrnry to Scale)S 1. -to <br /> t. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAUKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> J v f P <br /> i <br /> l2 <br /> PA MEN° <br /> RE Ellerl�._.. <br /> SEP 13 1985.. <br /> SAN JOAQUI <br /> �wBoeva..rE.oEEti ENVrltr..ONPTHSER ICES_ <br /> APPrw[leu Aca«leB By D.o. L A<«AL DI SlOfvy <br /> Grout lmp tion BY Del. P P In.p.otlon BY������IL-- <br /> Deat—tion Inspection BY De <br /> Commenu' <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODE{ FEEINFO MAOUNTRWITTEO 1CCHECMy2ASH I RECDVEDSY I DATEI —11"/SpNICE REQUEST NUMBER INVOICE <br /> rj �, OD i731 C�1��L1> 9I/3 9� FI QOaa973 <br />