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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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TRIpIkatl) <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WHII SAN <br /> JJOAQUIN COUNTY OB ADD E 8/OR APIJ/DEVELOPMENT TITLE.CHAPTER 8-111���I�STA I�DA e OF BAN JOAOU�COU��I�lTI1�RVICEB,ENVIRONMENTAL HEALTH DM8�1]O]N. _ ��O I <br /> {{JJ✓✓33 -T[�`V 1 'T117v1 rARCELL SIZE/APN/ I 1,-) <br /> OWNER'S NAME I Ia✓ - � � ADORE88 �I VJ.IL I Id� •y v Y -7upNE/ <br /> CONTRACTOR oe,4( Gff �e �t�or __"— ADDRESS <br /> SLOB CONTRACTOR a gcdc) <br /> (;1- - c4vUC/ PHONe QL A Z TN I <br /> TYPE OF WELL/PUMP; ❑ NFW WELL ❑ REPLACEMENT WELL Cl MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑New❑no'.1, HA. DEPTH PUMP BET FT. FIRST WATER LEVEL O <br /> (TYPE OF PL1MP1 <br /> ❑ OUT-0F-SERVICE WELL ❑ GFOF 4YSICAL WELL I J;J SOIL BONNO <br /> DESTRUCTION: `- Cft I I D?'�L POEN, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1�I �/1y. A <br /> 1:1 ��INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION p ILA DIA.OF CONDUCTOR CASINO �' v/ \ O <br /> 11DOMESTICR'RIVATE 11 GRAVEL PACK/BRE TYPE OF CASINO/STEEL+VC_ 4"L\ � OIA.OF WELL CASINO Ilk- <br /> D <br /> ❑ PUBLIC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL "�_✓Z° I.}-I,, SPECIFICATION R <br /> �11 <br /> IRRIGATION/AG ClOTHER �U Py� moo, GROUT SEAL INSTALLED BY u'eY GROUT BRAND NAME £ <br /> OROUT SEAL PUMPED: LRY- ❑No CONCRETE PEDESTAL BY DRILLER:❑Yw ly S <br /> IIAPPROX.DEPTH I (J 40 --I/�--11 LOCKING CHESTER BOX/STOVE PIPE t4 \�/�} S <br /> PROPOSED CONSTRUCT/OWDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS"ACT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIMNO OR 8V6-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SIIALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPE2/SATION LAWS OF <br /> CALIFORNIA.' T APPUC ANT MUST CALL 4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12051/I00-*422. COMPLETE DRAWING AT LOWER AREA PROVIDED. \ <br /> Blend X TI11e aEEElel,lJ I U Iy'� Det• Z V <br /> /LOT PIAN"—to 8aele1 Soel• —"to <br /> 1. NAMES OF ETRE 8 OR ROADS NEA BTT OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYSTEM OR PROPOSED 1 <br /> 2. OUTLINE OF THE PROPERTY,GIVING LONG AND NORTH DIRECTION. EXPANSION OF BEWAOE DISPOSAL SYSTEMS. ILN• <br /> 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PSOPERTY OR ADJOINING PROPERTY. <br /> VV <br /> U OTECHNIC IL;ONLY <br /> N <br /> Tlvo <br /> o C MIC ._. .. > <br /> HE AL <br /> X T <br /> ESTI (� <br /> � NC <br /> LANDUSE <br /> "-fT <br /> S �r <br /> MAR28M <br /> QumCOLiPJiI/ <br /> - t ,,� <br /> PUBLIC.L I .LTH s�M 0159 l 3� G:1'o­ <br /> um G <br /> IR NMENTA HEALTH DIVI-1ON' <br /> IS Gc� <br /> Aoplloetlon Aveepted Br - `� 1 `'�MENT USE ONLY !O /.�/O►�/L <br /> \ Dele <br /> Grout IrNP-0-By 0400 Pimp I-peetlen By Del• <br /> Dort-0-I-p-6-Fy ' 1 Oete��� <br /> f :r C <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED C EC !CASH RECEIVED BY DATE ►61MIT/SERVICE REQUEST NUMBER INVOICE <br />