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APPLICATION FOR WELLIPUMP PERNIK <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 366, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 133UE0 r I D <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRU(COMPISCT IANDMA(INSTALL THE WORK DESCRIBED,THIS APPLICATION IB MADE IN COMPLIANCE WITH S, <br /> JOAQUIN ADD COUNTY DEVELOPMENT!RLE,CHAPTER 9-1115.3 AND THESTANDARDSOF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DM910N. <br /> JOB ADDNEBBNR APHI J __ PARCEL SIZ <br /> OWNER'S NAME �Gi'C`VY \ �. N _` PHONE <br /> ADDRESS IV.�1�Y( 3�1�1�\. ^1 _PHONEIgA1l1•q�OC <br /> CONTRACTOR \ \V [�RO� nth -ADDRESS. UC/PLtS�I,.` pHONEI�IV�-q <br /> SVB CONTRACTOR ��- <br /> ADDRESS OCI PHONE I <br /> TYPE OF WELVPUMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I <br /> 1p INSTALLATION ❑ WELL SYSTEM REPAIR ❑ OTHER <br /> N.IJ Rep.lr H.P.�� <br /> •��Ippgll ❑ CR08S-CONNE��CyyT�I�REPAIR 1:1 VAPOR EXTRACTION WELL,,\0 <br /> RYPE OF PUMP( <br /> yL DEPTH PUMP BET`,JLJ1 PT. FIRST WATER LEVEL o V 1 <br /> f <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPrvSICAL WELL I ❑ SOIL BORING <br /> DESTRUCTION <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INOUSTRIAI OPEN BOTTOM DIA.OF WELL EXCAVATION A <br /> DOMERT1CrygIVATF GRAVEL PACK/SIZE DIA.OF CONDUCTOR CASINO I <br /> TVP OF CASINO/9TEElNVC_ �2 DIA.OF WELL CASINO <br /> ❑ PLMUCRAUNICIPAL 13DRIVEN DEPTH OF GROUT BEAL f <br /> ❑ IRRIGATION/AG ❑OTHER SPECIFICATION y <br /> GROUT SEAL INSTALLED BY <br /> 11 MONITORING BRAND NAME MONITORING GROUT SEAL PUMPED' ❑V. ON. E <br /> APPROX.OEM, !'� R CONCRETE PEDESTAL BY DRILLER❑Y. ON. S <br /> LJ LOCKING CREME,BOX/BTO VE PPF <br /> PROMISED CONSTRUCTION/DI ILLNG METHOD: MUD ROTARYJ <br /> AIR ROTARY AUGER CABLE <br /> OTHER <br /> I NEREBV CERTIFY TWAT 1 NAVE RIEPARED TH19 APPLICATION AND THAT THE WORK WILL BE ODNE IN ACCORDANCE WITH SAN JOAOVIN COUNTY ORpINANCEB,STATE LAWS,AND RULES AN <br /> REGULATIONS OF THE SAN JOAQUINAILL NOT COUNTY. <br /> THIS PERMIT IS ISSUED,18HALL NOT HOME OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOONG: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK PON WIC <br /> EMPLOY PELLWI <br /> MONS SUBJECT TO WOMAIAN't COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONTRACTING SIGNATURE CERTI�fE <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,18HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMNdSAT10N LAWS O <br /> CALIFORNIA.- THIS AM CANT MUST CALL 24 HOURS IN <br /> ADVANCE FOR ALL REGUNFD.lE(\�S\RUCTIONS AT IIOSI W-f1�12O�, •C^OMPIFTE DRAWING AT LTO W AREA PROVIDED.81Smt% ` \� �. \� \- TILL. 1� \ lel `'V \Q D.t.PLT <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE NPROPERT,. BwI. to <br /> 2. OUTLINE OF THE PRCKPTy,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM ON PROPOSED <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 6TRUCTVREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY ETON THE PROPERTY OR ADJOINING PROPER!,, <br /> O <br /> A�c� 2oA <br /> � U 41 <br /> 9 <br /> �Es7 <br /> B� FAST <br /> �oyT,Q�ile <br /> PAYMEN-,l 3o tip <br /> MAR 19 7996 n/ <br /> -�Hiv UaGUIr �:GL ` � d <br /> PLJ13LICHEALTH StRW F. <br /> civVIRONMENTAL HEAL(r, CSN no <br /> 1/ DEPARTMENT USE ONLY <br /> Aoplle.tlan Aeeyted By Ara <br /> pout Impectlon By DNe // <br /> D.-2l/b <br /> D.hwllen Imp.tlen By <br /> Da. <br /> Cerement•: <br /> ACCOUNTING ONLY: AIDI FACT <br /> NF COOFI AMOUNT REMITTFD HEC /CASH RECEIVED SY DATE <br /> RFRMITpp1VICE REQUEST NUMBER INVOICE <br />