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yjw <br /> :r,� o EV'.�.k'4�TW . �s�;v},,,;H; ..,v✓7s.,•�St:.7�e.��.:T�F.� <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL,HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES { YEAR FROM DATE ISSUED <br /> (Complete In Trilikefol <br /> APPLICATION IB HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THUS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COAUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB AOORMIMA APN/_ -330 �. Niti L,�yAJ G'Ic) CITY A C8M <br /> p 1,, -.{.. �j PARCEL SIZE/AMI <br /> CU NER C NAME_ff h1 IK-"'y ,[1� Ky A PICS yA y� �{• ♦ A001�Bt Ft�O].�a}�a,C l f a cfl M1g•�,CA ti;Z2p PHONE 8—i6: <br /> t f / <br /> CONTMCTORQQV��/�u fel F'(\J?A WI//(�/Yfl1'1lHVI/�1 i/L{ir ADDRESS -If.UJ�.gIII}�1J {yyr MZ PIONEI Y�7"/by'l! <br /> BUB CGWMCTOR� �� y�/1.I-}(,�,.�(n Qflll i, �,. m <br /> +=r T9 S IICI PHONE F <br /> TYPE OF S @LMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MO`WO_RLNO WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CAOSS.CONNECT REPAIR ❑ VAPOR EXTMCTMN WELL I <br /> TYP OF RIMPI <br /> 13N.ElP., H.P. DEPTH PUMP SET LEVEL <br /> FT. FIRST WATER LJ <br /> .�.� � D <br /> ❑ OVT-0FWELL ❑ GEOPHYSICAL WELL I ljI"BOIL BORING <br /> ESTRUCTION: Ror-11AN)8 PNlw F-9bm BAlII--.r j 'fi0 ToP.g <br /> INTENOED USE TYPE OF WELL CONSTRUCTION SPECIPCATIONS <br /> ❑INOVBTRAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION CIA.OF CONDUCTOR CASINO A <br /> 13 DOMESTIC/PRIVATE ❑OMroO <br /> GRAVEL PACKISIZE TYPE OF CABINOTEEI/PVC DIA.OF WELL CASINO <br /> 11 O <br /> IRIBUCIMUNICNAL ❑pIEVEN DEPTH OF GROUT BEAT SPECIFICATION <br /> 11 R <br /> IRItlOATgN/AG ❑OTHER OWVT REAL INSTALLED BY GIgVTBRANC NAME <br /> 13MONITORING <br /> e 4JRI [IN. F <br /> O GROUT BEAL MPEO: ❑Y. Na CONCRETEDESTALSYDRLLER❑ Na <br /> Yr ❑ S <br /> AX.OVTN o LOCKING CHESTER BOX/BTOVE RPE <br /> 111 ��� <br /> 0FOSm CONSTRVCTIONRNSlUMO METHOD: MUD ROTARY AIR IOTAPIY AUGER OTHER <br /> I W'tE@Y CERTIFY THAT 111AVE FREPAIB:D THIS A ATMN A THAT T11E WORK WRL BE DONE IN ACCOMANCE WITH BAN JOAMIN COUNTY.MINAMES.RATE LAW.,ANO RULES AND <br /> REGULATIONS IN OF THE BAN JOAOUCOUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IS ISSUED,I SNALL HOT EMPLOY PERSONS SUBJECT TO WORMAN'S COMPENSATION LAWS OF CALIFORNIA: CONTRACTOR'@HIRING OR SUSLONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORXMIIN'S COMPENSATION LAWS OF <br /> CAUFOWNA" THE APPILICANTIAUBT CALL 24 HOURS IN ADVANCE FOR ALL REOU.IEDrINSPECTION@ AT 12/#1441114M 2. COMPETE DRAWING AT LOWER AREA PROVIDED. <br /> nn. G29/S/ /f�N'KRP✓11Ca1 �44r�yv1 DN. <br /> PLOT RAN M,.I.Sa.1.1 Sa.l.�_•1e L� os��s /a <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY, S. LOCATION OF NOUBE SEWAGE DI.PO0 S STEM R ROTOBED <br /> 2. OIRLIRE OF THE PROPERTY,GIVING DIMENSONS AND NORTH DIRECTION, EXPANSIONCATON OF SEWAGE DISPOSAL SYSTEMS. <br /> 2, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED {, LOCATION OF WELLS WITHIN RADNt OF ONE HUNDRED FIFTY FT. <br /> STIKKTVRE/,INCLUDING COVERED AREAS SUCH AS PATIO/,DRIVEWAYS,AND WALLS. ON THE PROPERTY OR ADJOINING POPRTY. <br /> b�01K <br /> 2 3 FbK 2000 I; <br /> OWAATMFNT USE ONLY <br /> APPB..II.n A. I.d By <br /> Or«A In.oeellen Br mwl 6/tl/ iELWZd A1LJ� mu _ 1l A.nP ImP.Nan BY O.I. <br /> O.uuallen I.P.'b Br <br /> canmw.I.: !f13M • <br /> ACCOUNTING ONLY: AIDE FAC# <br /> K CODU FEF INFO AMOUNT REMITTED CHECUMASH RECEIVED BY DATE I'SPIMITRERMCE REQUEST NUMBER INVOICE <br /> i t �9-- 3 -rlom W071" i <br />