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�.d APPLICATION FOR VVELLIPUMP PERMIT z <br /> OG�63 S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.C. EIOX SK 304 EAST WESER AVENUE, STOCKTON, CA 95201380 <br /> (209) 488-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUER <br /> IComp16R In TriplkBb) <br /> APPLICATION IS THEM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WON(DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WRIT SAN <br /> JOAWIN COUNTY DEVELOPMENT TRLE,CHAFFER 81116.3 AND THE ST ID ROB OF SAN JOAQUIN COUNTY FyfUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMBION. <br /> Jon ADDREaSMA APNI CITY PARCEL 61EElAPNI <br /> OWNEIT'@ NAME ADORESB <br /> PHONE N <br /> CONTRACTOR ADOPEBS C RHONE <br /> OUR COMPACTOR ADOMBB <br /> UCI RHONE/ <br /> TYPE OF WEL M ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ,❑-, INS LLATION ❑ WELL SYSTEM REPAIR ❑ CR08SCONNE T R R ❑ VAPOR EXTRACTION WELL I ✓�• <br /> ❑Rm•Ir N.P. OEM"PUMPOET FIRST WATER LEVEL O <br /> �TTC' _ ❑ OUT OF-SSERVIC ❑ OEORHYGICAL WELL/ ❑ SOIL BONNO 8 <br /> ❑DESTRUCTION: XZ <br /> INTENDED TYPE OF WELL CONSTRUCTION SPECIFICATION6 A O <br /> FE��, DO��U6TRIAL ❑OPNBOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> LLLOMESTICIPRIVATE ❑GRAVEL PACK1817E TYPE OF CANING/STEELWVC DIA OF WELL CASINO O <br /> ❑ MBLICMUNWIPAI ❑DRIVEN DEPTH OF GROW SEAL SPECIFICATION <br /> ❑ IRRIOATbNIAG ❑OTHER GREAT SEAL INSTALLED BY GROW BRAND NAME <br /> 11 MONITORING GROUT BEAL PIMPED: ❑V. ON. CONCRETE FEOESTAL BYDRILLER:❑YP [IN-. 5 <br /> APPIOX.DEPTH LOCKING CHEATER NO)STOVE PPE S <br /> PROPOSED CONSTAUCTIONIDNWNO METHOD: MUD ROTMW AIR VOTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 11HAVE PREPARED THIS APPLICATION ANO THAT THE WOR(WILL BE DONE IN ACCORDANCE MTN SAN"AMIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> nEGUTATIONB OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIONATUM CERTIFIES THE FOLLOWING:•I CERTIFY THAT W THE KMORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 08 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN•AOON LAWS OF CALIFORNIA.- CONTRACTOR'S NINNO OR BUBCOWRACTINO BIONATI CERTIFlEB <br /> THE FOLLOWING: •I CERTIFY THAT IN TI AFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS HIRUED,1 @HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSAT <br /> PLION UW6 OF <br /> CAUFORNI T ICANT VST CA 4IIO IN ADVANCE FON ALL"FO AMEO71"s �A1�,G NS.A1T U1061408A4Ea. COMPLETE DRAMNO AT LOWER AREA PROVIDED.B.P IX DH. 4-� � <br /> PLON ID'.1.SeMel Seale •le <br /> 1. NAM 8 OF STREETS OR ROADS NEAREST TO OR BOUNOIN TIHE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM AA PROPOSED <br /> 2. OUTLAW Of THE PIIOPFRTY.GIVING DIMENSIONS AND RORTH DIRECTTGN. EXPANSION OF SEWAGE WAGEGN;pQDIL BYBTEISY <br /> 3.STRUCTURES. <br /> OIRLLM.t AND LOCATION OF ALL EXIkTWO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED iIFTV FT. <br /> S. <br /> BTRICTVREB,INCLUOING COVERED AREAS SUCH AS PATK)6,DRIVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING FROPERTY. <br /> t <br /> ;+ VCU l rLlr�11�9-Q, <br /> GJ•,r�k(/ ,z <br /> PAYMENT <br /> RECEIVED <br /> MAY <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> DEPMTM T USE ONLY <br /> APeSe•Ilen AeeapRed BY v DDo- <br /> Grout Imomlbn By la Fume In•PPllen BY���P//�I/j�r..� D•le���6 <br /> I I <br /> OwbaeOen IgPmtlon flv �, <br /> CemmstP <br /> ACCOINITINO ONLY: AUDI FAC/ <br /> PE COD" FEE INFO AMOUNT REMITTED HECK CASH RECDVEU BY DATE PDW11T16FIiWCFREOVEIT NIRABFR INVOICE <br /> * ff LZ <br /> Pub.Health SON.-Enviro.173(3/96) <br />