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('XPPLICATION FOR WELL/PUMP PER <br /> SAN-dOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 1,)4 <br /> {209) 466-3420 j <br /> I l�'1 <br /> f NON-RENNDARLE PERMIT EXPIRES 1 TEAR FROM DATE ISSUED <br /> Icemplel$I"TIIpReEllll <br /> AI'MICATIDN IS HERE BY MADE TO TIIE$AN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.TIRE APPLICATION IS MADE IN COMMIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND TIIE STTA_NDARDS OF BAN JOAOUII)COUNTY PUBLIC HEALTH SERVICE9.ENVIRONMENTAL NEALtH DIVISION, <br /> 4 JOB ADDRESSIOR APN# [Y V �}'E , 2 LTc CITY L/YI /� "CEL . ! I0 <br /> OWNER'S NAME i\a `--' on e ' ADOM98 M C— <br /> CONTRACTOR �. ADDRESS '� LTC# PHONE# <br /> SUO CONTRACTOR v' f✓ • ADOM4111 g.] Ini!*Q <br /> CAvK ucts <br /> �.eue <br /> !1 TYP£OF• ,,,_„ WELLMUMP, ❑ NEW WELL ❑ REiUCEmew WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL RYSTFM REPAIR CI CROSS-CONNECT REPAIR ❑ VAPOR EXTRACT tON WELL R(TYPE or PLFMI'l ,1 <br /> f ❑New❑rkhek 114.10. DEPTH PUMP SET rt FIRST WATER LEVEL O <br /> 13OUT-OF•SERVICE WELL ❑ OEOFIIYCICAL WELL R fLi SOIL ROMN0 r�' {D <br /> DESTRUCTION: <br /> INTENDED USE TYPE OF W CONSTRUCTION SPECIFICATIONS A <br /> I ❑ INOUSTMAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO o <br /> ❑ DOMERTICMMVATE ❑OMVEL PACKMIZE TYPE OF CARINOMTEEUPVC DIA,OF WELL CASINO O <br /> ❑ PURLICAUUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL NIT:CITICAT10N ) F <br /> f ❑ IRRMATIONIAG ❑OTHER GROUT SEAt INSTALLED BY GROUT BRAND NAME Cy S l W <br /> I ❑ MONITOMMO GROUT SEAL PUMPEDe❑Yee ❑He CONCRETE P INICTAL BY ORtLLtn ❑Y— ❑Ne $ <br /> APPROX.DEPTH LOCKING.CLIERTER BOX/MOVE PIPE S <br /> p PHOPOREB CONATRUCTTONMRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTIIFF _ �� <br /> I IIEnFAY CERTIFY TIIAT T HAVE PREPAMO TI119 APPLICATION AND THAT TIIE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOU[N COUNTY OBDINANCE9,STATE LAWk AND RORER ANO <br /> I REOULAT F TIIE BAH JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOlMNO:•1 CERTIFY THAT IN THE PERFORMANCE OF TIIE WORK FOR WIRCH <br /> ' TICI WHIT IS IS EQ,i%HALL NOT EMPLOY PERSON%SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA,' CONT VICTOR'S NINNO OR NUB-CONTRACTING SIGNATURE CERT 1TIE% <br /> TH TOLLOWING- 1 CERTIFY TITAT W THE PERFORMANCE OF TELE WORK FOR WIRCH THIS PERMIR IS 1%9VED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-0 COMPENSATION LAWS OF <br /> CALIiEORN1A.` TILE PPUt,ANT MU T C Lr, HO IN ADVANCE FOR ALL"COMBED IN$PECTTONS AT 12001 4@04422. COMPLETE DRAWING AT LOWER AREA PROVIDED.9 <br /> %Illnnd X Title AOL <br /> yL Sip* <br /> 20 2r <br /> �IIT <br /> 4 =j.0 4t.- <br /> 4F-PP AC, <br /> lb/s <br /> ` o y pQ•3enC. d TO ACI /4It <br /> U tiidv��le� <br /> T.. c <br /> 15 <br /> E E. <br /> 0 .Y.r•11Ja'} !/• � A 4.laAc. r ` >; LI die, 1 l , IJGJ(e <br /> k ti r 4C 7 4 p{�9• <br /> it <br /> 9 <br /> s <br /> 7tv 1.4' 091-07 <br /> f <br /> '1 AG�90 <br /> DEPARTMENT USE ONLY <br /> AFpllealtem Aaawl�eecl Ry _ T�� � 7 P� <br /> .: ...+�...,.. E ..., Dale`_ _` �/ A, <br /> I- �W` Q.tN .Pkr*+u 1nrPeellen Ry_.."•.•.w.•,_�"" <br /> Ilw.tnrfllen Irnrwniten B �_.' � Gala <br /> Date <br /> V <br /> ACCOUNTING ONLY, AID# FACE 1 <br /> PE COOPSFEE INFO AMOUNT REMITTED CFIEc JCASH RECEIVED SY DATE <br /> PERM11'sERVICE REOUEST NMM9ER INVOICE' <br /> I <br /> 3r 9 61 a9 1c.� <br /> Pub.Heallh Sem-ERviro.173(1197) <br /> f <br />