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APPLY ION FOR WELL/PUMP PERMIT <br /> SAN JOAOUITCOUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TFWICN1K) <br /> APPLICAMN IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDNR INSTALL THE WORK DESCRIBED.THUD APAICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOAAENT TITLE,CRAMER�0-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADI)RESBXIfl AMI /L30 j �yC �C �J�tiI �� CITY �/T�[J�C�iC`'7C�n� PARCEL SIZE/ARI# (� <br /> CONTRACTOR <br /> NAME_wwQ..��--L�2{f/�J7(-J'' •II- Vim//[]]_-f/tt77�]1Uaf ADDRESS �JZ5!'C sr�/// C MONEI <br /> COMRACTOR�LJ(/���},y I"-l(IY7/-- C' ADDRESS YCa� .�C t LN/1JT�LCYLC• L`� AIONr/ �.3/� O�CY) <br /> SUB CONTRACTOADDRESS me ATONE# <br /> TI PE OF WELLJPUMP: ❑ NEW WELL ❑ REAACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑N.0Recel, II.P. n DEPTH PIMP a" FT, FIRST WATER LEVEL O�- <br /> RYPE OF PIMP) f <br /> � <br /> n//1L)� EI UT <br /> O -or SSSERVIC/E'LWELL 11 GEOPHYSICAL WELL I SOIL BORING <br /> 1- qO <br /> DESTRUCTION- lk7P 12i12C_/f}'C/Y1 crN i <br /> cPo <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ACN <br /> INDUSTRIAL ❑ORNBOITOM DIA.OF WELL EXCAVATION DIA.OF CONOUCTORCASING 0 <br /> 4..MESTKATIVATE ❑GRAVEL PACK/BIZE TYPE OF CASINGATEEUPVC DIA.OF WELL CASING CJ, /-r_ 07� <br /> IVBIICRAUNICIPAI 13 DOWN OERTII OF GROW SEAL SPECIFIOATION q . <br /> INRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GRUNT BRAND NAME FCCC ��1 <br /> WHOOPING GROUT SEAL PUMPED. Ely- [IN. CONCNETERDESTALRYRRILLER:❑Y#F [IN. al <br />'PPRo%.RTYTN LOCKING CIIESTEn BOX/STOVE AR S <br /> ROMSM CONSTHM"ONRNSLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> HfYBY CERTIFY TNAT I HAVE PNEPAIIEU TNIS ARgICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES,STATE LAWS.AND RULES ANO <br /> REGULATIONS OF THE BAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TIIE FOLLOWING:-I CERTIFY THAT IN THE MAf00MANCE OF THE WORK FOR WHICH <br /> HIS KFAUT IS ISSUED,I MAM NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S UNMO OR SUB-CONTRACTING SIGNATURE CERTSGSS <br /> ISE FOMOVANO: -1 CERTIFY THAT IN TIIE RAFORMANCE OF THE WORK Fon WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS MaJEOT TO WORKMAN'S COMRSNSATION LAWS OF� <br /> ALIFORMA.- THE MIICANT MUST CALL M HOURS.DI ADVANCE FOR ALL FEOUIRM INSPE^CTIONS AT 12001480041423. COMPLETE DRAWING AT LOWER AREA IHD`VIDED.�j <br /> I.—I X �/�-i TISK— "�1/II_.y j/L 0.1. '- _f✓a �/ <br /> nor RAN IOea v R%Wei Ba.i. -to <br /> NAMES OF STREET O DAUB NE REST 10 on BOUNMNG THE POOMITTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR ITVlIOBED <br /> OUTLINE of 1NF R PERRY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> DIMENSIONED MMINFA AND LOCATION OF ALL EXISTMO AND P OPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY A. <br /> STRUCTUREB.INCLUDING COVERED APEAB SUCH AS PATIOS.DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING AbRRrv, <br /> 6 rAvi <br /> oo <br /> /3Dk'P <br /> PAYMENT <br /> MAY ,2 8 1998 <br /> SAN JQAQUIN GIJUN FY <br /> PUBLIC I lEALTH SERVICES <br /> �-DEPARTMENT USE ONLY <br /> mNutbn Aa.aPIM BY j �TL/�-/ D.b •Z Aye ( 1 2— <br /> nw I�npRllpn er RITC In.PICGGn qv <br />+IrlaHlpn UwPmHlen BY <br /> D.H. <br />•mmbX.: <br /> ACCOUNTING ONLY: ADI FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CNEC ASII RECEIVED SY DATE IETAIITISERVICE REQUEST M�UiNBBI INVOICE <br /> / 7 <br />,b.Health Sew.-Enviro.173(1/97) <br />