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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 /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (GampMla In Triplicate) <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOS ADDRE 89/OR API/ _ � � 1..� S ,)f i� - !�[ICfTY T-1 L PARCEL SIZE/APN/ �7/ {� 2 ''j <br /> OWNER'S NAME Tg�7 ( FO/I���.1 f/ Cy .aL ?5� 1--.C� '` Ri/ONE I,;]Ls'S '•3 �LT ("'7 <br /> CONTRACTOR�{/U1.1 cl S: fi)r5 i ! 5��f ' 441 i.-': ADDRESS P�.Q f.=C,Y f ,3 7 , dLIC/ LUrrr jam:PHONE <br /> ISZi{ <br /> SVS CONTRACTOR ADORE B@ � LIC/ PHONE F <br /> TYPE OF WELL/PUMP; I NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> LL//�J'J INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CSOSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ <br /> -S14 ❑New❑avok H.P. _ DEPTH PUMP SET/LS' FT. FIRST WATER LEVEL p <br /> HYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL f ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE {TYPE OF WELL CONSTRVCTION SPECIFICATIONS A <br /> py <br /> ❑ INDUSTRIAL OPEN BOTTOM DIA.OF WELL EXCAVATION ��. DIA.OF CONDUCTOR CASING rL�r:T•�L�L" p <br /> �DOMESTIC/19i1VATE ,/❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEVPVC ,p DIA.OF WELL CASINO <br /> 11 PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL /L�Gt SPECIFICATION [) R <br /> ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY 1410, j lj'j� l GROUT BRAND NAME7'rj-1[.i(- C'[.i,z.//-I E <br /> ❑ MONITORING GROUT SEAL PUMPED:W Y.. ❑No CONCRETE PEDESTAL SY DRILLER:❑Ye. CIN. S <br /> Ji J� y <br /> APPROX.DEPTH f I {�/ LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE x OTHER <br /> 1 HE9EBY CERTIFY THAT I HAVE PREPARED TWO APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAOUM COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,181PALL NOT EMPLOY PERSONA SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'@ HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMFT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' TOPUCANT M�FST-CALL 24 HO/URS I/N-.,AOVy,((*P#CE FOR ALL REGILMED INSM"ONS AT 12001 440-422. COMPLETE DRAWING AT LOWER AREA 7/PROVIDED. j <br /> 919—d X �".. '� .�l<� 1�"/V �.. TRIe C Q A a �='_:� C� f-3 2- - D.t. <br /> PLOT PUN M—to Sa Mel S.M. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE P'ROP'ERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH Dtr%FCTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EX19TING AND PROPOSED S. LOCATION OF WELLS WFTWN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SVC"AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 1'c' `Rp <br /> 1_ ?.. _. .. .. i ...;. V <br /> ..,_. .: <br /> : � .... <br /> p <br /> d v <br /> AYMEN 9 <br /> 1P 91 I <br />