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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES O D <br /> ENVIRONMENTAL HEALTH DIVISION O <br /> P 0 BOX 368,485 N.SAN JOAOUIN ST.,STOCKTON,CA 85201.388 <br /> (203)468.3420 <br /> NOR-REFUNDABLE PERMTT EXPIRES 1 YEAR FROM RATE ISSUER <br /> ECmARIete In TFiFSeetel <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT TIRE,CHAPTER 9-1115.3�AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH BEIMCEB.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDAESSIDR APNP [ aO �—��(!� ,CDY)VCYt�LAlJJPABC0.BRFIAPN/ <br /> OWNER'S NAME M.E, jkg0'1 [1e. ADDRESS� - I Lfv CL389'. <br /> cDNTRAcroR� ESS ouer ..r 23fy98A <br /> SUB CONTRACTOR ADDRESS LIC* }HONE 4 <br /> TYPE OF MP ❑NEW WELL ❑REPLACEMENT WELL. ❑MONITORING WELL s ❑OTHER <br /> ❑INSTALLATION ClWELLSYSTEM REPAIR 13cmas-cONNECT REPAIR L3 VAPOR E%TRAGTLDN WELL s J <br /> 0 N—WI P .. H.P, r DEPTH PUMP SET&O FT. FIRST WATER LEVEL_ O <br /> (TYPE yOF PUMPI T <br /> +L UA bl+t�L ISI,4 (sGL ❑ouT-o-mVICE wELL ❑GEOPRYsiCAL WELL# ❑ SOIL SGAING d <br /> ❑ <br /> DESTRUCTION- <br /> INTENDED USS TYPE OF WELL. CONSTRUCTION SPECIRCA71ONS A <br /> � <br /> ❑L INDUSTRIAL 13 OPEN BOTTOM AIA,OF WELL EXCAYATIDN DIA.OF CONDUCTOR CASINO O <br /> ey DOMEIITICIPNVATE ❑GRAVEL PAMISMk TYPE OF CASSIOIBTEEUPVC DIA.of WELL CAMk8 R <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> 13 IAIKIATWNIAG ❑OTHER GROUTSEAL INSTALLED BY GROUT BRANa NAME E <br /> ❑MONITORING GROUT MAL PIMPED:13Y. ❑NM CONCRETE PEDESTAL BY DRILLER:❑Y.. ON. 8 1 <br /> APPRoX.DEPTH LOCILMIS CHESTER BOX/STOVE PPE 8 O <br /> PROPOSED CONSTRUCTONMRIWNG METHOD:MVO ROTARY AIR ROTARY AUGER CABLE OTHER <br /> h <br /> I NEpE1LY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUNI COUNTY ORDINANCES.STATE lAYY6,AND RIIF.S ANO' <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENI^S SIGNATURE CEATIRES THE FOLLOWUIG:h CEA7IrV THAT IN THE PETIFORMANCE OF THE WORK FOR WHICH,�y <br /> THIS PFRAUT IS issm,I SHALL HOT EMPLOY PERSONS SUBJECT TO WOrJMM'S COMPOSATION LAWS OF CAUFOINIm CONTRACTOWS HIRING OR MAHXKTRACTINO SIGNATURE CU]RIFIES <br /> THE FOLLOWING: ,I CERTIFY THAT IN THE PERFORMANCE OF THE VwORK FOR WHICH THIS POurT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORgMANY COMPENSATON LAWS of <br /> CALRORMA,-THE APPR/ D <br /> APPLICANT MAST CALL 74 ROU IN ADVANCE MR ALL AHRED SItINSPSID7pT�NB AT 12=1 485442s.COMPLETE ORAWIMG AT LOWER AREA P OVIDW. <br /> SIW.a x„�'L,� Q i.... TRM�del..fPifJ Dw �3/Z R 9y A . <br /> PLOT RAN ak—t.So"S.d. -m Y <br /> 1.NAMES OF STREETS OR ROAD$NEAREST TO Oft BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GMNG DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPDSAL SYSTEMS. <br /> 7.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND OWPoem S.LOCATION OF WELLS WITHIN RADIUS GF ONE HUNDRED F6TY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAULS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> '. ...o... ....., 1... .. <br /> .. .. .. <br /> ... i <br /> L-R-+7.7 i ., i <br /> ' o.. <br /> .. ., ....... i... ..... r <br /> ..... .... - <br /> RAYMENTl�lc , <br /> FCtV .p _ <br /> JAM AT <br /> SAV JDAQLHN G(JtJNTY <br /> Q 'L?iNf 4L3 SL 6IIG4 <br /> ENVIRON MENTALHEALTH;DIMfSION ..... <br /> .... ... .... <br /> DEPARTMENT USE ONLY <br /> APGntfm Aaapt"BY czj ^D.n 1 <br /> arvA Daws-BY two PUIIp kSpaclkn BY OHB <br /> Cemmetx.: <br /> ACCOYNTSNO ONLY: /IIx FAcr <br /> R CODES FEE INFO AMOUNT AEMgM EC ASH RNEIVED BY DATE PS RARTISHMCE REOUEST NUMISE R INVOICE <br /> -3 6 <br />