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APPLICATION FOR WELLIPUMP 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 /> NOW-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Komplett M TrIORPBb1 <br /> APPLICATION IB NEPE BY MADE TO THE BAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT ANIMN INSTALL THE NOPK DESCRIBED.71118 APPLICATION IS MADE IN COMPLIANCE MH SAN <br /> K� JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1115.7 A�N-Dt THE STANDARDS OF B JOAMIN COU I PUBIK:HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION.JOB ADORSMOR A / _ r \ CITY PARCEL SI APNI <br /> OWNER'S NAME A... -` F- CFI I <br /> CONTRACTOR _ ADIDRSS - Y <br /> PUB CONTRACTORFTT� ADCRESS M, RHONE I <br /> TYPE OF MLLJPUMP: Y�,NEW WELL ❑ REPLACEMENT WELL ❑ MONITORIND WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROBS.CONNFCT REPAIR ❑ VAAc, EXTRACTION WELL E J <br /> Y'L vN•.v❑R•ew, H.P. DEPTH PUMP 9Ej2-s,2J. FIRST WATER LEW 0 <br /> I YFE OF PUMP) <br /> ❑ OlR-0FFFRVICE NTLI ❑ GEOPHYSICAL WELL I ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INMSTRAL 11 OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> 191DOMESTWN VATE 11 GRAVEL PACK/SIZE TYPE OF CABMORTEEUPVC DIA.OF WELL CASINO O <br /> ❑ PUOIC/MUNICIPAL ❑ORVEN DEM14 OF GROUT SEAL SRCIMATION A <br /> ❑ 1RNOATION/AG ❑OTHER GROUT SEAL INSTALLED BY OMM BRAND NAME E <br /> ❑ IMINMONNOCT GROUT SEAL RIMPEM ❑Yee ❑N• CONCRETE PEDESTAL SY DRILLER:❑Yr ❑N• S <br /> �J <br /> APFROR.DEPTH 7 a U_ LOCKING CHESTER SOX/FTOVE RPF 3 <br /> PROPOSED CONSTRUOTION/DRILONO METHOD: MUD RUTARY AIR ROTARY AMER CABLE OTHER <br /> I IIEYSY CERTIFY TIHAT I IIAVF PREPARED THIS APRICATKIN ANO THAT THE WOR(WILL SE DONE M ACCORDANCE WITH BAN JOAQUIN COUNTY OIOIHANCES,STATE LAWS,AND RULES AND <br /> REOULATIONS OF THE BAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTNIES THE FOLLOWING:"1 CERTIFY THAT W THE PERFORMANCE OF TIRE W W MR WHICH <br /> THIS PERMIT IB ISSUED.10IHALL NOT EMPLOY PERSONS"ACT TO WORKMAN'S COMM OISATION LAWS OF CALROIMA.- CONTRA MR-s NIRNO OR NSGONTIIACTWO SO TUR CERTIFIES <br /> THE FOLLOVANO! "1 CERTIFY THAT W TIRE PERFO ANC"OF T VAFK FOR VtN CH THIS PERMIT R ISSUED.1 SHALL EMPLOY PERSONS BUBJFCT TO WMOAAN'S COM SAOON LAWS OF <br /> CALIFORNIA" ANT MUST CALL I/ IN ADV E FOR ALL Awoul INS NB AT 1l7140ll lE. COMPLETE DRAWING AT LOWER ARA PROVIDE <br /> Kpr!XT c nn• Y� � o•I. <br /> ROT PLAN RR•w 1•B•r•I ba•I• Is <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PFORRTY. /. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P OPOGED <br /> E. OUTLINE OF THE FIORRTY,OIVI O DHAEENSONS ANO NORTH DIRECTION. EXPANSION OF BEWAOE DISPOSAL SYSTEMS. <br /> J. DIMENSONEO OUTLWFS AND LOCATION OF ALL FXISTWO AND PROPOSED S. LOCATION OF WELLS WTTIIIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED ARIAS SUCH AS PATIDS,DRVEWAYS,ANO WALRB. ON THE PROPERTY OR ADJOWMG PROPERTY. <br /> 'S� y <br /> � r <br /> y kdtiild/i <br /> q SEF <br /> aNVIRONMENT/U.HEALTHULJIsilI, <br /> J VwwL .•EJ�/ <br />