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i APPLICATION FOR WEIIlPUMP PERM' - <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388,304 EAST WEBER AVENUE. STOCKTON, CA <br /> (209) 469-3420 ft- 1/ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDy <br /> (Complete in TTlplleate) /VW-te 9S'z ` ! 9 ��L <br /> APPLICATION IS HERE BY MADE t0 THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION t6 MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT T[TL "AFTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> s+ Max !, RJ. J <br /> JOB ADDREBSroR DPN! GITY f!' G�ti( V J1 P CEL at <br /> ZElAPNI <br /> OWNER'S NAME J{J Ct�'6 fAV Lt C.. •�--IDYL(•-�J ADbRESQ PHONE I L U d Gi <br /> CONTRACTOR ADDRESS �t[)N LIC[ PHONE A <br /> i <br /> SUB CONTRACTOR ADDRESS LIC[ <br /> PHONE Y <br /> TYPE OF WELLIPUMP; ❑ NEW:WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 0 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR I�( CROBS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑New❑flepelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP[ r t7 <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING g <br /> ❑DESTRUCTION: <br /> INTENDED UBE TYPE:OF WELL CONSTRUCTION SPE CIFICAT107[6 <br /> A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/8RE TYPE Of CASINO7STEELIPVC DIA,OF WELL CASINO <br /> D <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> R <br /> IRRIOAT10N7Ap ❑OTHER GROUT SEAL INSTALLED 6Y GROUT BRAND NAME E <br /> ❑ MONRpRING GROUT SEAL PUMPED: ❑Yaa ❑No CGNCRETE PEDESTAL BY DRILLER:❑vaa [IN. <br /> S <br /> APPROX.DIEPTH LOCKING CHESTER BOXmTOVE PIPE <br /> S <br /> PROPOSED CON3TRUCTIONIWpLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WtTH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND; <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIER THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IQ ISSUED,I SHALL NOT EMPLOY PERSONS SU13JECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: .1 CERTIFY THAT IN THE PERFORMANCE-������QQQQQQF THE WOR TOR.WHICH THIS PERMIT[@-ISSUED.I SHALL EMPLOY PERSONS SUBJECT-TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE Pl1CANT MUST CALL 4 HOURn[ A�VANCIF FOR ALL REQUIRED IN/PECTION9 AT 130914�342a, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Slpned X f- Data !� <br /> PLOT PLAN[Draw to Soerel Seale 'to / <br /> T. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. I <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEMS.SYSTEM OR PROPOSED <br /> EXPANSION 6F SEWAGE DISPOSAL 9Y9TEM8. I <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. .I <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE ProPERTY OR ADJOINING PROPERTY. <br /> € (4 <br /> iI[ <br /> [L1r'v�1i+JYar�h <br /> X :� �.�j:US.S :C..oila'1�� <br /> :. ... "' v ��fi .. r <br /> ehv>s <br /> ... <br /> I <br /> . <br /> Sr,.ta JiJA ansa coLlrjsr: . " <br /> 6'.14E4�SN 5 j Is) SION <br /> T <br /> DEPARTMENT USE ONLY <br /> AppBeetlen Acr•.epted Ay h <br /> `-" �Area <br /> Grout Impertlon By Date Pimp Impeetlon Ryt� e(.. •� Date <br /> bmutretlon impaction 9y i - bate <br /> Corn ftmv j ,f <br /> p r <br /> ACCOUNTING ONLY: AID#' 1 � <br /> ( FAc;T <br /> PF CODES FEE INFO gAMOUNT REMITTED \ CHEC t7CAef1 RECEIVED BY DATE PERMITIEEAVICE REQUEST NUMBER INVOICE p� <br /> I <br />