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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAN JOAOUIN ST.,STOCKTON,CA 96201.388 <br /> (2091498-3470 <br /> NDN•AEFUNOABLE PERMIT E%PIAES I YEAR FROM GATE ISSUED <br /> rAmpleM h Trpliaa) <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORN DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN <br /> J OuiFI COUNTY DEVELOPMENT TFTIEC,JC/HAFTER 9- <br /> /111 S.3 AND THE STANDARDS <br /> SSJOf IC <br /> GAN JOAQUIN COUNTY PUBLIC HEALTH SERVES,ENVIRONMENTAL HEALTH DIVISION.JOB ADDRESIVOR APNP Z�/ Lf1 Z L-r-1y /"V <br /> fCITY �/ICt�V PARCEL&2E/APw_ <br /> OWNER'S NAME i ADDRESS PHONE ' <br /> _ CONTRACTOR ./LPL.//.1/J L G[�jJ /e /�iJ/L ADOREBG'% / FNONE I ]J !�� <br /> SUIS CONTRACTOR_ ADDRESS LICP _PHONE P <br /> TYPE OF WELL PUMP: L NEW WELL ❑NEPLACEMENT WELL ❑ARINROPoNG WELL P ❑OTHER <br /> �PISTALLATION 11 WELLSYSTEM MPAIA ❑CROSSdONNECT REPAIR ❑VAPOR EXTRACTI7N WEEtiJI <br /> /:2 ❑WNr H.P. _ DEPTH PUMP SET�FT. FIRST WATER"zL_ O <br /> (TYPE Of PJNN`i -41 <br /> ❑OUT-0F•SERVICE WELL ❑GEOPHYSICAL WELL I ❑ SDR BORBE:l $ (y, <br /> ❑DESTRUCTIONZ <br /> INTENDED V. R ON ATIO A <br /> ❑IMUSTRI/LL ❑OPEN BOTTOM DIA OF WELL EXCAVATION DIA.Of CONDUCTOR CA _8N0 D <br /> Pi-MESTICMBVATE ❑GRAVEL PACXAIZF TYPE OF CASINCIGTEnJPVC OLA.OF WELL CASING D <br /> ❑PUBLICRAUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A Ecr <br /> ❑RiEOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E e <br /> ❑MONITOFINO GROUI SEAL PIMPID.❑Yr [IN. CONCRETE PEDESTAL BY DFYLLFR:Ely- ❑Na 5 R <br /> APPROX.DEPTH _ LOCKING CHESTER BOXNTOVE RPE__ <br /> PIEDIVS[D CONSTRLCTIONAIEWNO METHOD:MUD ROT Airy AIR ROTARY AUGER _CABLE OTHER (((�I <br /> 1 HEREBY CERTIFY THAT I HAVE~ABED TNS APPLICATION AND THAT THE WOW WIL BE DONE IN ACCOMANCE WITH SAN JOAaNN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> KEOULATOONS OF THE SAN JOAOUN COUNTY,HOME OYNEA 04 LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLONINO:'I CEPR THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PEFMFF IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT CO WONKMAN'S COMPENSATION LAWS OF CALIFORWA.'CONTRACTOR'S HIRING OR SUB—NiRACTNO SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CEIITIFY THAT IN THE Pf7EOMMNCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS 8USJECT TO WOLEOAAN'S COMPpISATMN LAWS OF <br /> CAUFORMA.'�THHE Amp/jP,UypANT MUST CALL <br /> /E/POU"IN ADVANCE FOR ALL MALMO INSPECTIONS AT 12101 MI. =,COMPETE DRAWING AT LOWER AREA PROVIDED. <br /> SNID14 X !'//GZ�fH /t.<JC�J�� _iNM d'�LT_ DnA <br /> PLOT PLAN ID'—"6aWl <br /> 1.NAMES OF STREET$OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION GF NOUBE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTFMB. <br /> J.DIMENSIONED OUTLINES AAO LOCATION OF ALL EXISTINO AND PRDPOSEp [.LOCATION OF WELLS WITMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTVKS,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,API;WALK8. ON THE PRIOR ADJOINING PROPERTY. <br /> / <br /> /// <br /> n4 <br /> B <br /> PA MEWL <br /> AUG 2 4'1995 <br /> SAN JGA <br /> j <br /> PUBLIC <br /> �u11 Ct;ula i c <br /> ..rNVIROA N EALTy L7,�., CES <br /> MENTAL kEALTH ptVlSrp� <br /> : 1 <br /> —,NRTRIENT uEE ONLY 1 r H <br /> ApF[oa,bn AaaRP,aO eY_��. ��(j7� DaN1✓.A,����Cq�Fv,! <br /> GrpA IrNPc<ian By— "Dna P+TD I-POMan a,- <br /> ANN, <br /> YAI, FAC. <br /> FE c«Fl FVEINFO AMOUNT REMITTED CHEC A:ABN ITEC 9VED■Y DAT[ A[ NWICS <br /> 0 35a.oo 4-70-f 3 <br />