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do b <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388,304 EAST WEBER AVENUE,STOCKI'ON.CA 95201388 <br /> (209)469.3420 <br /> 001-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IC"Jaill In TrIIIII"fe? <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PFVAR TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE 04 COMPLIANCE WITH BAN <br /> JO AOUN COUI(TY DEVELOPMENT TALE.CHAMTR 8.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY/PUBLIC HEALT)f SERVICE!,ENVIRONAENTAL HEALTH DIVISION. <br /> JOB ADDRFS"R APR! 4/�D f /1 r77 eh,pal cR-r �j I!L'/ {a SS-:!� 71 PARCEL SIWAPNI / (, <br /> OWNER'S NAME PG.rrI�k <br /> C . 6Zej Zr <br /> n <br /> CONTRACTOR �s'T/LP, J� AMAUDIEDR66ESSOQ <br /> W, /J� UDI -PHONE! <br /> ctle CONTRACTOR ADDRESS YL?E'7: (�J. ✓�'�c! PHONE! <br /> TYPE OF WELLIPJMP, ❑NEW WFLL ❑REPLACEMENT WELL ❑MONITORING WELL P ❑OTHER_ <br /> ❑I.N(�MLLTI <br /> STAAON Ll WELL SYSTEM REPAIR ElCROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL!• I�,/` <br /> St"E [LNM oRsvll H.P. DEPT14 PIMP SFT/ELFT, FIRST WATEiI LEVE <br /> TYPE OF PUMP) II <br /> ❑.OUT-OF 6"ME WELL ❑OEOFHYSICAL WELL E ❑ BOIL nonom <br /> ❑DESTRUCTION: v y <br /> INTENDED �lyPE OF W CONSTRLICT10M SPECIFICATIONS <br /> ❑INDUSIRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION D.A.OF CONDUCTOR CASINO D <br /> ❑DOMESMM"VATE ❑GRAVEL PACKUSIZE_ TYPE OF CAMNOMTEELPVC _ OLA.OF WELL CASINO <br /> ❑PUBUCOMLINK:IPAL /❑-I DRIVEN DEPTH OF"OUT SEAL SPECIFICATION <br /> ❑IRRIOATIONIAG ❑OTHER GROUT DEAL INSTALLED BY - GROUT BRAND NAME ❑ <br /> ❑MONrDORINO GROUT SEAL PUMPED:❑Yr ❑N. CONCRETE PEDESTAL BY DRILLER:❑Y- Ne <br /> RO <br /> APFX.047TH LOCKING CHESTER S0X/BrOVE PW- <br /> E-- <br /> CONSTRIICTION/pIBLLU1N)METHOD: MUD ROTARY AIR FOTARY AUGER CABLE OTHER <br /> I HEREBY CEATWY THAT I HAVE PREPARED THIS APPLICATION AND MAT THE WORK WILL BE DONE IN ACC—DANCE WITH SAN JOAQUIN COUNTY 01OMM/CES,STATE LAWS,AND RULES AVON <br /> REGULATION@ OF THE SAN JOAQUIN COUNTY,HOME OWNER ON MENRED AGENT'S SIGNATURE IN <br /> THE FOLLOWSNG:-I CERTIFY THAT IN 1 H FE?VV"ANCE OF THE L'ADI K FOR <br /> THIS PERMIT IB ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WOR7WIAN'S COMPENSATION LAWS OF CAIJFOPMA.'CONTRACTOR'$HIRING OR SUBCONTRACTINO 00NATUIE CERT <br /> THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(COR WHICH THIS PEMAR IS UIVAO,I$HALL EMPLOY PERSONS SUBJECT TO MgIgiAN'S CONIF"SATION LA <br /> CALIFORNIA.' M A ANT MV1T CELL 24 IIOUJtA IN ADVANCE FOR ALL REQUIRED INSPIOCTIaNS AT 420q)44111111.24". COMPETE DRAWING AT LOWER AREA PROVIDED, L J <br /> Blyud X_ a���r� TUU. <br /> PLOT MN 0—Ie 9.0.1 5..1. <br /> 1.NAMES OF STREET$OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. A.LOCATIONOF HOUSE SEWAGE DISPOSAL SYSTEM OR PIOP09E0 <br /> 2.OUTLINE OF THE PROPERTY,GIVING ORAENSOKS AND NORTH DIRECTION. EXPANSION OF SEWAGE V46POSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES MIO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WFULI WITHIN RADIUS Of ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH M PATIOS,DRIVEWAYS,AM WALHN. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> Y <br /> d r <br /> Y►i'i.%itti i S' <br /> �9iTEC <br /> m <br /> mAY <br /> N,f'I FI :iilY JIJMI!'J lM.rCIU�:1 Y .. • <br /> F`•� DAMTMENT USE ONLY <br /> Ao.u.Hl.n <br /> Ac—Id S, ` DM. M� <br /> Grout Irwp.cllan BY_ D.I. P-,1-0-BY D— <br /> Or,.Ilellen Ir+ ,[-eY D.t. <br /> AccounneG once: MO! FRCP <br /> FT <br /> INVOICE <br /> CODES FEE INFO AMOUNT MATTED CHFC ,CMH RECBVED$Y DATE T NUMSpI <br /> ' '0 -�aa �7q1 /� <br />