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APPLICATION FOR WELLIPUMP PERP <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEMACES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9,,201-W <br /> n w (209) 469-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Icamptals <br /> I <br /> Arn ICAtION IS IIEnE RV MADE.TO THE SAN JOAOUIN COUNTY TOR A PERMIT TO CO NSTRUCTAND/on INSTALL THE WORK DESCRIRED.THIS APPLICATION IS MADE IN COMPLIANCW <br /> JOAQUIN COUNTY DEVELOPMENT TRLF,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEAL H SERVICES,ENVIRONMENTAL HEALTH DIVISION. E RH SAN <br /> JON ADOnFSS/On APNI (� ' P S 1 (p <br /> OWNER'S NAME CITY_ s�p �— 4,C- 4/� <br /> �� y]G PARCEL SIZE/APN/ <br /> � <br /> ' <br /> ADDRESS' R/ONE <br /> CONT MCTOR_. �� In �r �( y-� -1 ' <br /> UC/ �j U P110NF I 5d-� <br /> SUR CONTRACTOR <br /> ADDRESS UCl P//ONE <br /> TYPE OF WELUPUMP• ❑ NFW WFLL ❑ RFPLACE MENT WELL ❑ MONITORING WELL <br /> Cl OTHER <br /> ❑ INBTM LATION 11WELL SYSTEM nEPAln ElCnOSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> �Z V L ,L e 11 New KYRep.ir / ./ <br /> II.P.�_ DEPTH PUMP SETT. <br /> RVPf OF 1`VMPI FIRRT WATER LEVEIO <br /> 13 ❑DESTRUCTION: OUT-OF-SERVICE WELL ClDEOPNYSICAI.WELLI ❑ SOIL BORING <br /> R <br /> INTENDED UCE TYPE or WELL E6"T UC itON SPECIFICATION{ <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION A <br /> ❑ [X7MESTIr/PRIVATE ❑GRAVEL PACKISIZE DIA.OF CONDUCTOn CASINO n <br /> TYPE OF CASINO/RT EEIR'VC DIA.OF WELL CASING n <br /> �� AJPUC/Ml1NlCIPAL ❑DRIVEN <br /> DEPTH OF Gno UT SEAT. SPECIFICATION R <br /> �f­IRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY <br /> GROUT BRAND NAME F <br /> MONITORING <br /> APPROX.DEPTH GROUT SEAL PUMPED' ❑Yu ❑Ne <br /> CONCRETE PEDESTAL BV DRILLER:13Y— ❑Ne ,y <br /> LOCKING CHESTER ROX/STOVE FYPE <br /> S <br /> PROPOSED CONSTRUCTION/DRRUNQ METHOD: MUO ROTARY AIR nOTAnY <br /> AUCFR CABLE OTHER <br /> 111"FRY CFRTIFV THAT 1 HAVF PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND FtULFS AND <br /> RFnUI ATIOrie OF THE SAN JOAQUIN COUNTY, HOME OWNFR On LICENSED AGFNT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOn WHICH <br /> THIS PERMIT in ISRUFn,1 AVAIL NOT EMPLOY PERSONS SUBJECT TO WOnKMAN'f COMPENSATION LAWS OF CALIFORNIA.- CONT MCT 09'8 HIRING OR SUR COW RACTIN SIGNATURE CERTIFIES <br /> TIIE FOI.IDWINn: 1 CFRiIry THAT IN TIIE PFRTORMANC OF THE W017C FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SURJF.CT TO WORKMAN'S COM dATOH UWS OF <br /> ' CAIJFORNI AP CANT MU{T CALL 1516 ADVANCE FOR ALL REQURFD INTIOHE AT 120111p J12]. COMPLETE OMWINO AT LOWER AREA FTAViDf.D <br /> Slpned x <br /> Tltle S 7 <br /> D.te <br /> PLOT PLAN IDrew to So.Iel R-1. 'to <br /> 1. NAMFR OF RTnFET9 OR ROADS NFAnERT TO OR ROUNDING THE PROPERTY, <br /> 7. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 1. LOCATION OF HOURS SEWAGE A SR'YST E SYSTEM OR PROPOSED <br /> 3. DIMFNFOONFD OU7tINFS AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION F SEWAGE DISPOSAL SYSTEMS. <br /> ON <br /> RTnUCTUnFR,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION OF WFILS ADJOIWITHIRADIUS PE ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOINING PRO Pf STY, <br /> I <br /> AN <br /> IL <br /> rt. loc'j <br /> PAYMENT <br /> _ J <br /> 1� <br /> 1 <br /> s <br /> SEP 2.31997 <br /> SAN JCN .IIUIN Ct:UNPUBLIC HEALTH f r" <br /> ENVIRONIVIENT'AL.H AE HI1 Slim' (: ,�jo� <br /> ry�liV <br /> DFPAATMENT USE ONLY / <br /> Applleetlen Aeeepted By_ � ���-� Dae <br /> Tovt In.peeeen By Da• P,r p In.pealen By <br /> DMtnrtlon I-pe 11—Ry__ Da. <br /> Cemmer.H' <br /> ACf.OIINTING ONI Y: AID/ FAC/ <br /> PE CODER IEE INFO AMOUNT REMITTED IIEC I A811 nrcnvrn By DATE PERMIT/1111RVICE REQUEST NUMRFP INVOICE <br /> 43:lc ID50 50 Zf L20 a�+ �� ► <br /> Pub.Health Serv.-Enviro. 173(3/96) <br />