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APPLICATION FOR WELL/PUMP PERMIT [� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES CO) <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Camplfl[ In TTIpRestf) <br /> APPLICATION in HERE BY MADE.TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONRTRUCT AND/OR INSTALL THE WOGK DESCRIBED.T1119 AM'LICATION IR MADE IN COMPLIANCE"T11 SAN <br /> JOAQUIN COUNTY DEVELOPMENT RIf CHAPTER -11 B.3 AND THE ATARI�RD,JB OF RAN�pAOV CQ�( PUBLIC-HEALTH SERVICER,ENVn10NMENTAL HEALTH DIVIRION. <br /> JOB AODnFSS/On APN/ C% -t�--c-�—r—ry���') L�7 3 `CJ PARCEL IZE/APR/- a ( ,� <br /> a't ,�—`- <br /> OV4Wn'R NAME <br /> �.�,. 1 • ADOGFSR 630 CJC� �'T- F4IONE 1 S7ti��75 r <br /> CONTRACTOR l C iL V1.�\ y�.'Q ADDRESS Ct 1 �� '\e.n'��LIC/ PHONE I ( <br /> jKJ 7 } <br /> RUB CONTRACTOR ADDRESS �.�,� LOCI / MIONE f <br /> TYPE OF WELLIPVMP; ❑ NEW WELL ❑ REPLACEMENT W ❑ MONITORING WELL I LJ OTIIER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ C11088-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL S •I <br /> (TYPE OF R/MPI ElN—❑mrow, H.P. DEPTH PUMP BET FT. rtnST WATER LEVEL O <br /> ❑ OUT-0E-SERVIOE WELL ❑ nFOM1YSICAL WELL f ❑ ROIL SOIVNG q <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF W CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p <br /> ❑ OOMFIITIC"IVATE ❑GRAVEL PACKI9IZE TYPE OF CASINO/RTEELMVC DIA.OF WELL CASINO O <br /> ❑ PURLICAUUNICIRAL ❑DrSVEN DEPTH OF GROUT SEAL SPECIFICATION '7 q <br /> ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT`BRAND NAMR-(1 <br /> ❑ MONITORING OROVT REAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑Ne t <br /> APPnOX.DEPT" LOCKING CHESTEn BOXIRTOVE MPE S <br /> PROPOSED CONS TRUCTTONIDWWNG METHOD: MUD ROTARY Ain ROTAITY AUGER CABLE OTHER J� <br /> I HERFRY CERTIrY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOPK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OIIDINANCES,STATE LAWS,AND RULES AND <br /> nEOLn.ATION8 or THE RAN JOAQUIN COUNTY. HOME OWNER OR LJCENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PEnFORMdANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IR ISRUED,I RIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATTON LAWS Of CALIFORNIA.- CONTRACTOR'S NIRINO OR RUNCONTRACTINGSIGNATURE CERTIFIES <br /> TIIE FOLLOWING: I CERTIFY TH �PIIWOPIAAJICE Of TIIE WOPK FOR WHICH Till@ PfFUNTT 18 ISBVED,I SHALL EMPLOY PERSONS RURJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFOLL ' HE APN'UCANT M n ADVANC[FOR All REOIXREDfNf►[CTIONS AT(2051 ISSSNZl. COMPLETE DRAWING AT LOWER Al1EA PROVIDEO. <br /> Rlprwd X 1 � Tltl. L f D.t• �J <br /> KOT PUN M,—to S-4.1 Ra.l. 'fe <br /> 1. NAMES Or STREETS On GOADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF NOURE SEWAGE DISPOSAL SYSTEM On r710POSED <br /> i. OUTLINE OF THE P110PERTY,GIVING DIMENSION8 AND NORTH DIRECTION. EXPANSION OF SEWAGE DIamm SYSTEMe. <br /> I. DIMENSIONED OUTLr NFB AND LOCATION OF ALL EXIRTING AND PPOPOSED S. LOCATION OF WELLS WITNIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AR PATIOS,DISVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINIIO PROPERTY. <br /> VA <br /> �5 <br /> �LK�Q <br /> _ RR''��pp <br /> .. y � .r �/ �� .: .. rh'N ENT <br /> � AUG 10 1998 <br /> el <br /> ( SAAN JOAQUIN COUNTY. <br /> Vl\ 0 PUDLIC 1EALTH SER�+ICES <br /> LENVIRONM "iNTAL HEALTH DIVIS " <br /> I <br /> l <br /> _. .. .. Pt� (I <br /> DEPARTMENT USP ONLY <br /> APPIIe.tlnn Aeeroterl BY V� IL <br /> O.t. ti V V A...�l <br /> 0reu1 Imooe Herr By D.b ' Pump Impeetbn BY ON. <br /> De.truellen Lwneetbn Rr <br /> CernmerN.: <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODE$ FEE INFO AMOUNT REMITTED I -i IEEiICASH RECOVED BY DATE PETIMITISFAVICE REOI/EST Nl1MSEA INVOICE <br /> Pub Health Serv.-Enviro. 173(1/97) <br />