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APPLICATION FOR WELUPUMP PERMIT <br /> 1 SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES 0 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX M 904 EAST WEBER AVEMJE.STOUMN,CA 96201388 <br /> avy <br /> (2091 499-3420 ; <br /> N ! FUNDANLE PERNNT EXPIRES 1 YEAR FNDNI DATE ISSDED <br /> (GIIIPINE in TIwifEf) <br /> AP►)CATION le HERE eY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONIT MILT MI"INSTALL THE WDM(DESCIN[D.THIS APPLICATION It MADE M COMPLIANCE WITH BAN <br /> JOAQUIN COtwn Y DEVELOPMENT TITLE..CHAPTER B•111 B.3 AND T1EE STANDARDS OF BAH JOAQUIN COUNTY <br /> - PUPUBLLICHHEALLTHSEERVICES.ENVNYfNNIMAL HEALTH W <br /> ISION. <br /> Jos AjDRE'D&gn s i cm PARCEL 9l2lUPN0 <br /> OWNER'SNAME_U.lCA)DM%,jj CaUF- 91N*OCA <br /> ADDRESS SA Mo �Csz. PHONE,-5-W 11$47 <br /> COIRMCTCIL y)E'c&..—puinap C-C) ADDRESS / r 71 JDY,�a PORE# Q <br /> SUB COMPACTOR ..S [�-('y"'NJ ✓�'� uCS PHow f <br /> IY_PE OF WLLNVMP. ❑HEW;MOLL ❑REPLACEMIENT WELL ❑MowroRSM WELL I ❑OTHER.- <br /> 0 <br /> THER`❑NST�A�LLL.��ATH N [I WELL SYSTEM REPAIR ❑CILOBFNN <br /> COECT REPAIR ❑vApon E%TAACTIO�N2W .1 <br /> .�ELLS <br /> ���E•K/!w ❑N-C�ey,.k H.P._��(� OEPTH PUMP SETFT. FIRST WAT/R LEVEL LL/ O <br /> cnf Cl ouT-*P-EERVN:E wFu ❑oEonnelcAL wn1 A 11 *OIL aoMNa = f <br /> ❑DES R=TION: <br /> INTENDED USA Ty"OF WELL SRHTFILKTION NS A <br /> 1T❑1T�R�INCUIIT/EAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION T.M.OF CONDUCTOR D <br /> LLTDOMESTIC/PISVATE ❑GRAVEL FACK/HZE_ TYPE OF CASINGNTEELPMC DLA.OF WELL CAMq,- <br /> ❑FUBLXIMUNICPAL ❑DRIVEN DEPTH OF GROUT SEAL _ SPECIFlCAT7DN yc <br /> ❑ SEG <br /> BATOWAO ❑OTHER GROUT SEAL INSTALLED BY ORoUr BRANo NAME Q <br /> ❑MONITORINGORoUT SEAL PUMPED:❑Y.. ❑N. T CONCRETE PEDESTAL NY DIM❑Y.. ❑N. d <br /> APMOX.DGPTN — LOCKING CHESTER SoXmTOVE RPE_ V <br /> PROPOSK CONSTRUCTIONCIRLING MSTHOW MUD ROTARY AN ROTARYAUOER__ CABLE OTHER <br /> I NE`EfY CERTIFY THAT 1 HAVE PREPARED THIS APIL)CATgN AND THAT THE WORK WKL BE DONE N ACCORDANCE VAT"SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES <br /> REGU ATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR IJMO SED AGENT'S SIGNATURE CERTIFIES THE MLLOWM:'1 CERTIFY THAT IN TIRE PWWID99AANCE OF THE WORK FOR WHIG <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WINIKMAN'S COMPEISATMN CAWS OF CMJFOPMA.'CONTRACTOR'S HIRING OR Sub-CONTRACTING SIGNATURE CERTIFlEf� <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK Fon WHICH THIS PERMIT IS ISSUED-1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&C-OMPONATRIN LAWS O <br /> CALIFORNIA.' LICAM MUST CALL>•IIOMARS ADVANCE■M AL:.R&dI1P1iD IMS Tpi AT<IdN.M�Z7.COMPLIER[OMMANG AT lAWE11 MEA ROVIDED. <br /> $18-11 X 1 - �'7— ThN__ !l M� I. <br /> ROT RAM ID—m S.WI <br /> 1. NAMES OF STREETS OR ROADS IEMEST TO OR BOUNCING THE P10FERTY. 4-LOCATION OF HOUSE SEWAGE DMFOSAL SYSTEM OR PROPOSED <br /> 2. O VTUNE OF THE PROPERTY,OWING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS..; <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXIST NG AND PROPOSED E-LOCATION OF WELLS WITHIN RADIUS OF ONE ESINOREO FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED PREM SUCH AS PATIOS,ORVEWAYS,AND WALKS. ON THE PROPERTY OR ADJODGNO PROPERTY. d: - <br /> ...<. . .. <br /> c�+LRa-.. _.. . n► <br /> U CCG Yte I <br /> PATM <br /> y•. <br /> : . <br /> '..... > ..:. : . . .. . ; ;.1.1196......,... .`.....: .. <br /> triitll'1i h/I.VyIV'F'Y'"' <br /> . . .. ..i.....: .:....: <br /> A <br /> . .`.. :.. ;...: ..>. . M1 .; ....: Ll .MEAL:. ..tfFtVIC)=S ...............- <br /> JVP. IJMEIV.T�1L.(1EaL7H f)1VIS)ON. <br /> DEPARTMENT USE ONLY <br /> By t�y.y�yy //•• <br /> APNa.11a+A.a.Pttl _ f <br /> o.l. Arr <br /> deal Irop.e4.n er— O.t. Pun.1n.F..tl.n By �Dr. <br /> C.m.rrdm: <br /> ACCOI:NTING ONLY; AIRF FACN <br /> M.coon FEE INFO AMOUNT A RATTED CHEt�,'v ASH RECDvEO■Y DATE PPEMMTMOWPCB KnounT NUMBER INVOICB <br /> 4n 0 <br /> d y s <br />