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oc q <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468420 <br /> — NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Cempla$In Trlpk*l$I <br /> APPLICATION 49 HERE Ry MADE TO THE SAN JOAOUW COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,THIS APPLICATION 18 MADE IN COMPLIANCE MTll SAN <br /> JDACMN COUNTY DEVELOPMENT TITLE,CHAPTER 9 r'Y `--1115.x.13 AND THE BTANOAROS OF BAN JOAOMN COUNTY MAIM HEALTH SERVICES,ENVIRONMENTAL HEALTH nms ON, <br /> JOB AODWSSlOR APNr J S O I �`/� Cmr Lp li ' r ,Ir PARCEL SIZFJAPNI <br /> OWNER'S NAME O r '410 /r�AbDl�66 Sb S .L• I/O T PHONE I <br /> CONTRACTOR L ; f r► AX�60 h "� ADDRESS /301 4 . AK !r LFCr PHONE r 3 6 Sp 8'L.- <br /> SUB CONTRACTOR ADDRESS UCr PHONE 9 <br /> "OF WELLIPUMP; ❑ NEW WELL CI REPLACEMENT WELL ❑ MOWOPAM WELL R ❑ OTHER <br /> ❑ INSTALLATION xWELL SYSTEM REPAIR 11CROBS Cr <br /> II <br /> (TYRE OF PUMP) __ I -sONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> sµFP ❑N.�Rmpo4 H.P. _ -? DEPTH PUMP SET FT. FIRST WATER LEVEL p t\ <br /> le <br /> ❑ OUT-OF-BERVIC WELLf(0 ❑ GEOPHYSICAL WELL/ ❑ BOIL BORING g `� <br /> �' ❑OEBTRIICTbN� 1�/\1 <br /> INTENDED USE TYPE OF WtM CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p <br /> ❑ DOMESTICA''RIVATS ❑GRAVEL PACKlBIZE TYPE OF CAB1NG18TEELiPvC DIA.OF WELL CA91NO p <br /> ❑ PI78LIClMUWIPAL ❑DRIVEN DEPTH OF GROUT REAL SPECIFICATION q <br /> ❑ IRRHGATIONIAG ❑OTHER GROUT REAL INSTALLED BY GROUT BRAND NAME F <br /> ❑ M WTGFJNLG GROUT SEAL PLIMPFO: ❑Yr [IN. CONCRETE PEDESTAL BY DRLLER:❑Yw [IN. S <br /> APPROX.DEPTH LOCKING CHESTER BOXMTOVE PIPE S -- <br /> PROPOSEb CONSTRL/CTIONfiWLIOM METHOD: MVD ROTARY AIR ROTARY AUGER CABLE OTHER -5 <br /> I HE9FRY CERTIFY THAT T HAVE PREPARED THIS APPUCATION AMC THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULER <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PFWORMAHCE OF THE WORK FOR H <br /> THIS PERMIT 18 ISMIEO,I SHALL NOT EMPLOY PERBON8 BVBJECT TO WORKMAN-$COMPENBATIDN LAWS OF CALIFOFMA.- CONTRACTOR'S"FONG OR 811"ONTRACTINO SIGNATURE CERTIIIE <br /> THE FOLLOWIPIG: ERTIFY THAT IN THE IRTORMANCE OF THE WORK FOR WHICH THIB PERMIT IS MMMO,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMFM6ATION LAW$OF <br /> CALIFOR HIA.- T ANT MUST C LIPS Ut ADVANCE FOR ALL REOUPRED IN TIrON$AT 12081 4444422, COMPLETE DRAWING AT LOWER AREA PROVIDED, <br /> vp <br /> 8*-o X L TI <br /> v D�t� �/^ <br /> PLOT PLAN Wrr to Sa.Isl Sale 'to <br /> 1. NAMES OF STREETS OR ROAOS NEAREST TO OR BOVNDNG THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> R, OLJFLINE OF THE PROPERTY,OWING 011MENSION8 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> S. blIMENBGDNED OVTUNF.$AND LOCATION OF ALL EXISTING AND PROPOSED S, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES.INCLUDING COVERED AREAS 8UCH AS PATIOS,DIQVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> L3 <br /> I RFT, FP <br /> i JUN 11998 <br /> SAkN 7i AUi_Jw4 uuL N fY <br /> ll r ` PUSUC HEALTH SERVICES <br />