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APPLICATION FOR WELLIPUMP PERMIT <br /> `. SAN JOAOUIN COUNTY PUBLIC HEALTH SE..w;ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 38MMI EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> �j (209( 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAI <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN# S, CRY o�//�///C PARCEL SIZE/APN# <br /> OWNER'S NAME ADDRESS ��Oj ��/�� �,7 E�N�r��r /r�PHONE# /pyNd2�"./V� <br /> CONTRACTOR �� / / ADDRESS 124;0 46]14, LI� UC/ q OI PHONE O/.* I <br /> SUB CONTRACTOR Nim/// ��_T/a�L+� ADDRESS S25; 0 � NEa �S //d <br /> TYPE OF WELLIPUMP:10 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL IF ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# r <br /> �N..v❑R.P.Ir H.P. DEPTH PUMP 6EL_FT. FIRST WATER LEVEL E <br /> TYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B <br /> ❑DESTRUCTION' <br /> INTENDED US TYPE OF WELL CONSTRUCTION SPECIFICATIONe l� A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> 'ZDOMESTICA'NVATE WGRAVTL PACK/BRE TYPE OF CASINGMTEELJPVC DIA.OF WELL CASING A E t D <br /> ❑ MBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 7�©I� r L lzG.Q/y,�SPECIFICATION er �,0 R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY �` A592SAOUT BRAND NAME E <br /> ❑ MONITORING /J�(/y,%� 1. I GROUT BEAL PUMPED: ❑Yr [3 No CONCRETE PEDESTAL By DRILLER:❑V� 1,S <br /> APPROX.DEPTH_4 -Z 1 1 r CC LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTAUCT101%m01HWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9ESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANI <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S WONATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICI <br /> THIS PERMIT 18 ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-8 COMPENSATION LAWS OF CALIFORNIA.- COWMCTOWG HIRING OR SUBLOWT CTING SIGNATURE CERTIREI <br /> THE FOLLOWING ICE 1 THAT 1 RA <br /> RANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 @HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIO LAWS 0 <br /> CALIFORNIA. T M URS IN ADVANCE FOR ALL REQUIRED INSPNJ <br /> EC QEIy4 AT I2o!H 4423. COMPETE DRAWING AT LOWER AREA PROVID <br /> @Iprrtl X Tltl. .�/C` ��' DNe / <br /> MOT PLAN IOr.w to BW.)Sub to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PRDMSEn <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. N THE PROPEOR ADJOINING PROPERTY. <br /> < <br /> o � <br /> �( x c �� � <br /> v rarl�, <br /> Ici <br /> APR 2 4 19 6 <br /> "ItN <br /> TAL ff A1TH (;Et <br /> DEPARTMENT USE ONLY <br /> Appliwtbn Ap tN By �I,- D.I. 1 <br /> 01"ImPeptlen Det. / Pump lmpsllon By p.b <br /> Dstruetbn tmN tlon ByD.t. <br /> ACCOUNTING ONLY: AID# FAG <br /> PE CODES 64-64M AMOUNT REMITTED LHEC /CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> a7LS0/ <br /> r7�7 <br />