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�- APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAOUIN ST., STOCXTON, CA 96201-388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IlComy APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT kta, <br /> RUTA WOINSTALL THE WORT(DESCRIBED.THIS APPLICATION IS MADE IN COAAPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVROPM-EjNT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN# /So )3 1 <br /> CITY ]� <br /> OWNER'S NAME 6 PARCEL SIZEIAPN# <br /> OWNER'S NAME_!5+ <br /> �. <br /> CONTRACTOR ADDRESS <br /> {�� ` /��q PHONE# <br /> Y��yJ �'x� nIQ YYIdI`Dk L1C�► ,J <br /> SUB CONTRACTOR ADDRESS <br /> ADDRESS <br /> # PHONE# <br /> ~ TYPE OF WELLIPUMP- ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONfTORNG WELL It <br /> ❑ OTHER <br /> ❑ INSTALLATION V WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPA ❑ VAPOR EXTRACTION WELL# <br /> IR W ❑New 0 Repair H.P. J6 DEPTH PUMP SET FT. FIRST WATER LE <br /> (TYPE OF PUMPI ` <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORINGVEL O <br /> DESTRUCTION: _ <br /> INTENDED VSE TYPE OF WELL CONSTRUCTION SPECIFICATIO Nf <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION A <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE DIA.OF CONDUCTOR CASING D <br /> TYPE OF CASINGISTEEL/PVC <br /> DIA.OF WELL CASING D O <br /> PUBLK:/MUNK:IPAL ❑DRIVEN DEPTH OF GROUT SEAL <br /> SPECIFICATION '?�.]RRGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY <br /> GROUT BRAND NAME E <br /> ❑ MONITORING <br /> APPROX.DEPTH GROUT SEAL PUMPED: 0Y [IN. CONCRETE PEDESTAL BY DRILLFR:❑Yee N. S G <br /> LOCKING CHESTER BOXISTOVE PIPE <br /> S <br /> PROPOSED CONSTRUCTIONIDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE <br /> — OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES A D <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORNIA." THE APPUCINT MUST CALL 4 HOLIRS IN ADVANCE FOR ALL REQUIRED IN6KCTTIpIO��N8 AT(200)4883423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> w Signed 17 11 /V <br /> Tltla <br /> PLOT PLAN 113—to Scale)Seale•t_ , gyT I��Q,i ®��lL` <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOS`cD E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ,x <br /> d <br /> i R3 <br /> -faceSPAYMENI <br /> 4 MAY 2 6 199$ <br /> ES <br /> p`'�' <br /> SAN JUAQUIN LuuN3Y <br /> PU NM HEALTH AL HDIW <br /> /VffTr ENVIROiJMEIJTAL HEALTH C)IViStCt, <br />