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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JOAQUIN ST, STOCKTON,CA 95201-3BB <br /> (209)4883420 <br /> MOIL-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IcoAPPLICATION IS HERE BY MADE TO THE BM1 <br /> AN JOAQUIN COUNTY FOR A PEF (F TO CONSTin <br /> AEND/OR INSTAL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH Sµ <br /> JOAQUIN COUNTY DEVELOPMENT TIRE,CHAPTER 9-1115.3 AND THE STAJdDAADS OF SµJOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DRASION. <br /> Joe ADDRESS/OW APNr :::J�: <br /> CffV- PARCEL SIZE/APNI <br /> OWNER'S NAME kipd <br /> -�v ADDRESS /b�Ctl2 DHOW I <br /> CONTRACTOR a�bs Z il-J /' ADORES IJCI Ci-s 9In / FHDNE 1�y <br /> SUB CONTRACTOR ` ADDRESS -i/1�1cC ` <br /> LICf/ PHONE <br /> TYPE OF WELL/PMP ❑ NEW WELL Cl REPLACEMEhT WELL ❑ MONTT.NNG WELL/ ❑OTHER <br /> �(�� ❑INSTALLATION DELL Sy TEM REPA R ❑CROSSCONNErCTTREPAIR ❑VAPOR EXTRACTION WELL I J <br /> RVPE OF PUMP) ❑"°w❑"�'Ir H.P. DEPIM PUMP SETIATI FT. FIRST WATER LEVEL <br /> ❑OUT-0F-SERVICE WELL Cl GEOPHYSICAL WELL I ❑ SOk BORING <br /> B <br /> ❑DESTRUCipN <br /> INTENDED USF YpE OF WE11 CONI RRICTION SPBCIFICATIONr <br /> A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p <br /> �DOMESRC/PRVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA_OF WELL CASING D <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R I <br /> ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E LT' <br /> Cl MONITORING GROUT SEAL PUMPED:❑yy ❑Ne CONCRETE PEDESTAL BY DRUER:Ely— ❑Np S S <br /> APPROX.DEPTH ROCKING CHESTER BoxA;rO VE RPE S <br /> PROPOSED CGWTRIICTq N/01111JWG NET HOD: MUD ROTARY AIR ROTARY AUOEfl CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE NARK WILL BE DONE IN ACCORDANCE WITH SµJOAUUIN COUNTY ORDINANCES,STATE LAWS.AND RULESµD <br /> PEOULATIONS OF THE SµJOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'&SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TT1E VJOAK FOq yy 4CH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSON&StRIJECT TO W011xMµ'{COMPEN{ATOM LAWS OF C1111' CONTRACTOR'.MRH.OR SUB .lKACTWG SIGNATURE <br /> CERTIFI <br /> ES <br /> THE FOLLOWING 'I: CERTIFY THAT IN THE PERFt M ANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS BUSJECT TO WORICAM't COMPENSATION LAWS OF`< <br /> CALIFORNIA.'rTHE APPLICANT ,E CALL 2244 HOUII IN ADVANCE FOR ALL Motmt LI IF TIONJt AT 11011 Nt 3422_COMPLETE DRAWING AT LOWER ARE <br /> D t'A VIDE `'F�1 <br /> Skrra X /V�J�f A.� Tltls V <br /> PLOT PLAN IDr—la SW.)SuM 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P OFOBED <br /> 2. OUTLINE OF THE PROPERTY,GIVINO DIMENSIONS AND NORTH DIRECTION. EXPµBION OF SEWAGE DISPOSAL SYSTEM&. <br /> 3. DIMENSIONED OUTLINESµD LOCATION OF ALL EXISTING AND PROPOSED t. LOCATION OF WELLS E DISPOSAL <br /> THIN RADIUS OF OPE HUNDRED <br /> STRUCTURE.,INCLUDING COVEREn AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. DD FIFTY FT. <br /> ON TETE PROPERTY OR ADJOIMNG PROPERTY. <br /> SSSS.. .:. ... <br /> . SSSS SSSS... SSSS .. SSSS.. SSSS. - <br /> . SSSS. .:. .. ... ... . SSSS.. ...:. <br /> SSSS: SSSS. <br /> .. SSSS. SSSS . <br /> .... : . . .. ...:. . . <br /> . is <br /> . . . . . ........ <br /> DEPARTMENT USE ONLY —J <br /> AppYullon Acoepbd BY�L A <br /> Grout kuppction BY Arse <br /> Pvmp By_ <br /> Dob <br /> De4[rtctwn Ingeccion By <br /> - n110 <br /> Commant� <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODEC FEE INFO OUNT REMITt— CHEC /CA4H RECEIVED BY GATE IT/SERVICE REGUEIT NUN4B iEl <br /> SlLfaDa <br />