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i ^ APPLICATION FOR WELLJPUMP PEST <br /> E T <br /> SA JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> ROM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OR1E ISSUED <br /> ICompMN In Triplk*1*I <br /> APPLICATION IB HERE BY MADE TO THE SAN J WIN UN-Y FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHA 5.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY�P�U�BLILIC NFAILLTH SERVICES,ENVIRONMENTAL HEALTH DMBIIOONN.(�,�ir <br /> JOB ADUREBSKIn APNI G c;z CITY / /YI Y PARCEL SIZEIAPNI y <br /> ppp-.-Z/ 111��� ��'��'���/ n✓l� y� 31141 F'K w. <br /> OWNER'S NAMES 1�- L .,//J_//_•"'P ADDRESS SJZC♦.�rJ'LTN�fA- �J S �� ATONE <br /> I /^ <br /> 1 CONIMCTOR �EJNF Wit/C ADDRED8 DCI IRONER o! <br /> PUB CONTRACTOR ADDRESS LICI - PRONE 0- <br /> TYPE OF WEURUMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> [I m6TALLATION ❑ WELL SYSTEM REPAIR ❑ CmSB.CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> IJ N«v❑Re.d1 H.P. DEPTH PIMP BET__". FIRST WATER LEVEL O <br /> 11Yn OF <br /> PUMPI <br /> ❑ OVTAVI <br /> F-SERVICE WELL ❑ GEOPHYSICAL I BOIL BODING B <br /> ❑DESTRUCTION: <br /> IN1fN0EO USE TYPE DF W CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 <br /> ❑ MMESTM"IVATE ❑GRAVEL PACK1812E TYPE OF CASINUIBTEELNVC DIA.OF WELL CASINO D <br /> ❑ P BLICIMUNICIPAL ❑DRIVEN DEMN OF DROVE SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT BEAL INSTALLED BY OMW BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑YBB ❑N. CONCRETE PEDEBTAL BY DRILLER:❑Yr ❑N. 5 <br /> APPPO%.OERN <br /> /p LOCKING CHER/En BOX/STOVE APE S <br /> PROPOSED CONSTRUCT10NN LUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE DINER <br /> l E0 PF" <br /> 1 HEREBY CERTIFY THAT I RAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACC AWE WITH BAN J AOVIN COUNTY ORDINANCES.VATE LAWS.AND RULES AMU <br /> rCOULATIONB OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CFTUIFY THAT IN THE PERTOnMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB IBBUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFONNOV CONTMCTOR'B AIRING On BUB CONTRACuNG SIGNATURE CERTIAEB <br /> THE FOLLOWING: -I CEITTIFY THAT IN THE PERFORMANCE Of THE WORK Fun WHICH THIS PERMM IS IBBUED,1 SHALL EMPLOY nnBONB SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE A��PPLI7C7ANT MUST CALL] NGURS IN ADVANCE FOR ALL REQUIRED INSPECTION*AT MOST AS!1 S22- COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> @IIP.dx 2;2 - __Till GO. <br /> OL IIS% GH. <br /> not FILAR RP.I.S..I.I <br /> /r��. A. LOCATION OF HOUSE SEWAGE OIBPOBAL SYSTEM On PWPOGED <br /> 1. NAME@ OF Butt"S OR MADS NEAREST 10 On BOUNDOm THE PROPERTY. E%PANBION OF SEWAGE DISPOSAL SYNTEMB. <br /> ' i. OMUNE OF THE PROPERTY,GIVING DIMENSIONS Am NORTH DIRECTION. S. LOCATKIN OF WELLS WITHIN RADIUS OF ONE HUNDRED FIT' <br /> NO R. <br /> 3. DIMENSIONED OUTNEB ALOCATION OF ALL E%IBTING AND PROPOSED ON TIIE P10PERTY OR ADJOINING ApnRTY. <br /> STRUCTURES INCLUDING COVERED AREAS SUCH AS PATM8,DRIVEWAYS ANO WALKS. <br /> UWNTY <br /> '.� -pLl�l C.HFALTi3 SERVIDFS <br /> j .� '. tivlfinND.M1ENTAL HEALTH Db •' <br /> � t�71GzvP/�rJ�T Q. <br /> Sly /�rJlftiG '��N <br /> i I <br /> -- 1974 <br /> ...:...... <br /> it-4911210 <br /> ncn INC. 7140113276 PEC• <br />