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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRE? 1 YEAR FROM BATE ISSUED <br /> ICImpIIN In TTIpRenbl <br /> AMICAMN In HERE BY MADE TO THE SAN"AMIN COUNTY POR A PERMIT TO CONSTRUCT ANOIDR INSTALL THE WOR(DESCRIBED.71115 AMICA]bN IS MADE IN COMPLIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.0 AND THE STANDARDS OF BAN JOAWIN COUNTY P-U_BLIICC HEALTH SERVICED,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADDRESSAIR APNI L,l�� 41 S�, '.� 99 _�,K w Ly CRY yG�{ W PARCEL DIZEIAPN/ <br /> OWEIER'E NAME ADDR98 ��� YI, • p�C��yC� <br /> COMPACTOR -tzl �- ;�- ADIMIFBH A.EO A UCEAN(J 31r.2- PHONE <br /> Y�M�CS� <br /> PVB COMMCTOR ADDRESS NC/ PHONEI <br /> TYPE OF WELTJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION Cl WELL SYSTEM REPAIR ❑ CROSS{ONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑_ Nwv❑IYpFM H.P._I j� DEPTH FVMP SET -ILOiT. FIRST WATER LEVEL O <br /> Fa OF PUMPI 1E]�IE_�Gp ,tl,M <br /> ❑ OVT-0E-SERVICE WELL ❑ OMPHYSICAL WELL I ❑ SON BORING S <br /> ❑DESTRUCTION' <br /> INTENDED Ulf TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDIISTMAL ❑OPENBOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> XDOMESTICn VATE 11 GRAVEL PACK/StZE TYPE OF CASINOISTEEL/PVC DIA.OF WELL CASINO D <br /> ❑ PLISIM:IMUNOIPAI ❑DRIVEN DEPTH OF OPOM SEAL SPECIFICATION R <br /> ❑ m AT"HIAO ❑OTHER GROIN SEAL INSTALLED BY OROM BRAND NAME F <br /> 114M WOW" GROW SEAL PUMPED: ❑Y- ❑N. CONCRETEPEDESTALBYORILLER:❑Y- CIN. 5 <br /> APER IX.DFPEH I�- LOCKING CHESTER SOXRROVE RPE 5 <br /> PROPOSED CONSPRIICTION/DMLtDEO MFTI D: MW ROTARY AIR ROTARY AMER_CABLE OTHER <br /> I HERESY CERT"THAT PLANE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN"AMIN COUNTY NOINANCES.STATE LAWS.AND m S AND <br /> REOt TIONS OF THE SAN"AMIN COUNTY. HOME GVINER OR INCENSED AGENT'S SIGNATURE CEMNIES THE FOLLOWING:-1 CERTIFY THAT N THE PEHEORMANCE OF THE WOPR MR WHICH <br /> THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WOPKMAN'I COMPENIATION LAWS OF CALWOIMA.- CONTRACTOR'S MM OR SUR.CONNRACTNO SIGNATURE CEERNRS <br /> THE FOLLOWING. I CEMIFY THAT N TIE PERFORMANCE OF TINE WOfN FOP WHM;N THIS fEPAER IB ISSUED,I SHALL EMPLOY PERSONS SU FCT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- TWA C MT CALLEA Ml W ADVANCE FOR ALL REOUIRFD INS¢t MRS AT ISOSI*00 COMPLETE DRAW' AT LOWER AREA PIONOM. <br /> � <br /> elP�.e z� / TDI. o.I. <br /> MOT PLAN 10,—1.IM..t Ik.l. I. <br /> 1. NAMES OF STREETS OR ROADS NEAREST 70 OR BOURNNO THE PFOPERTY. /. IOCATON OF HOUSE SEWAGE DISPoSAL SYST[M OR PPoIOSFO <br /> S ONLINE Of TM PROPERTY,ORAD DIMENSIONS AND NORfM gFECTON. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 1. DIMERSICHM OUTLINES AND LOCATION OF ALL EXIIIFINO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUMPED Fn IT <br /> STRUC1V11FS.NCLMINO CO VEPED AREAS SUCH AS PATIO*,DMVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINNO PROPERTY. <br /> c <br /> 1 <br /> , ger <br /> R <br /> AYOfi! y - <br /> $ x _ <br /> JUN 5. <br />