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APPLICATION FOR WELL/PUMP 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 /> MMAEFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICImpIEu In TTbRe[hl <br /> APPLICATION IS HERE BY MADE TO THE SAN JO AMIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.TMS APPLICATION IS MADE IN COMPLIANCE WITII SAN <br /> JOAOVIN COUNTY DEVELOPMEENT TITLE,CHAPTER B�1119.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PU <br /> BLIH <br /> ICC yEAAL�T14 SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADONJIMR AMSytiy� .)D a CITY (�.�,j LOW PARCEL SIZVAMI <br /> -3t.- ce Co,OAR'B NAME AORE88 <br /> CONTRACTOR AOOREBB IN I&-/to&V(O1{/ <br /> ST Lx:001 p/Z NmEoImr e3c 47 <br /> PUB CONTRACTOR ADDRESS LICE RHONE I <br /> TYPE OF WELLJPUMP: ❑ WW WELL ❑ M"CEMFNT WELL ❑ MONITORHO WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WE <br /> ,LLSYSTEM REPAIR C1CROSS{ONWCT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑_ N—El „M. N.P. ! 4 DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> O IMPOi RI 'f'7.'E.iy_,C/`r ���TTTFFFTTT��� <br /> �� ❑ OUT-DF SERVICE WELL ❑ OMPHYRICAL WFLL I ❑ BOIL ROVING B <br /> ❑OERTRUCT ION <br /> INTENDED US f TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INMSTRAI ❑OPEN BOTTOM VIA.OF WEI.L EXCAVATION MA.OF CONDUCTOR CASING O <br /> X.DOMFSTICF VATE ❑GRAVEL PACKISIZE TYPE OF CAMNOISTEELNVC VIA.OF N'ELI CASINO O <br /> ❑ PUBLIC MUNICIPAL ❑DRIVEN OEPTH OF GROUT SEAL SPECIrICAT10N R <br /> ❑ IRROATIONIAO ❑OTHER GOUT SEAT.INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONVONNO OOUT SEAL PVMPEO! ❑Yr ❑Ne CONCRETE PMESTAE BY DRILLER:❑Ym ❑Ne 5 <br /> APPRCK.DIEL /�� LOCKINO CHESTER BOXISTOVE RPE 5 <br /> PROOSED CONSTRMTIONNRWNO MfTI O: MUD ROTARY AIR OTARY AUGER CARLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPIICATIOH AND THAT THE WOR(WILL BE DONE N ACCORDANCE WITH SAH JOAOUIN COUNTY RDINA ICES,STATE IAWB,AND RULES AND <br /> REGULATIONS OF THE SAN"AMIN COUNTY, HOME OWNER OR LICENSED AOEM'B SIGNATURE CERTIFIES THE OLLOV N -"I CERTIFY THAT NL, HE RNIOPMANCE OF THE WDPK OR WHICH <br /> THIS FERMIT HS ISSUED,1 SHALL NOT FMROY PERSONS SUBJECT TO INOAXMAM'S COMPENSATION LAWS OF CALIFORNIA.- CON RACTORB HIRIIO OR BUB{OMMCTNO SIGNATURE CERTIFIES <br /> THE <br /> THAT W"it FIFFIFORMANCE Of TW IoVORK TOM <br /> H THIS <br /> RMIT 10 ISSUED.I <br /> TO <br /> CAUFO oOOHE APAPI CIS MVS CALL 24 MUMS IN ADVANCE OR ALL MEMINEIiNf PLMINE At MINH�S•L".. COMPLETE DMNII�EATTLOWER AMAA/PROVIDEpPOISAnGpN uwe OF <br /> ffl N"z�/ SJR / D.I. (P—� 7 ^< 9 <br /> nor PLAN N...v le Se.I.I M.I• le <br /> I. NAMfS Of Bt REEtS OR ORDS NfAREBT TO OR SOUNDING THE R0IFRTY. 4. LOCATION OF HOUSE SEWAOE DISFbSAL SYSTEM OR PROPOSED <br /> i OUTLINE OF THE PROPERTY.GIVING D0,CFEI IRS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTNO ANO POOOF0 E. LOCATION OF WELLS WTTHHN RACIUS OF ONE HUNDRED FIFTY <br /> STRUCTURES,INCLVVIH I COVERED AREAS BIICN AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR"MNINO PROPERTY. <br /> 1 <br /> ©Qcn,� U <br /> 1 <br /> I <br /> I <br /> Un 'C41w y � <br /> iit119P`." <br /> IL <br /> ....._... �1( <br /> APPIIe.Ibn Awwl"BY D Tµ9/T USE ONLY <br /> G.ea Ir. I.Br D.,. R.nP ImamOe By <br /> Oslnstbn IgnmHbn By O.I. <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKE ASN RECEIVED■Y DATE FERMITUFTIVICE RMVEST NUMBER INVOICE <br /> gq S L11) ,let <br /> Pub Health Saw -Enviro.173(1/97) <br />