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,y a ���� APPLICATION FOR WELLIPUMP PERMIT <br /> I, �Iu SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �T �y ENVIRONMENTAL HEALTH DIVISION <br /> lnJhj � P 0 BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201388 <br /> lS (209)4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Comp6to in Trpliutt) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAGUM COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLJCATION IS MADE IN COMPUANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STAND S OF SAN JOAACOUPUBIJC HEALTH SERVICES,ENVIRONMENTAL HEALTH DI �JOB ADDRESS/Oq APN/�i C 6eW4 PARCEL SIZE/ 1 rOWNER'S NAME ADDRESSPHONE JCONTRACTOR ADDRELIC 7T/ pHDNE J,�' tl <br /> SUB CONTRACTOR ADDPESB UC/ T PHONE/ <br /> TYPE OF WELL/PUMP: NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL/ ❑OTHER <br /> ❑INSTALLATION Cl WELL�SYSTEM REPAIR ❑CROSSCONNECT REPAIR 11 VAPOR EXTRACTION WELL J j <br /> (TYPE OF PUMPI <br /> 11 N—Cl R", H.P. T <br /> _ ela DEPTH PUMP SET FT, FIRST WATER LEVEL O O <br /> 13OUT-OF-SERVICE WELL 11GEOPHYSICAL WELL I ❑ SOIL BORING B <br /> Cl DESTRUCTION- tV <br /> INTENDED UCE TYPE OF CONSTRUCTION SPECIFICgTION y� A m <br /> ❑INDUSTRIAL ClL'OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINGh p <br /> ❑DOMESTIC/MVATE GRAVEL PACK/SIZE TYPE OF CASING/STEELJPVC DIA.OF WELL CASING p <br /> m❑/E��PUBLI^C/MUWCIPAL ❑DRIPTH DRIVEN DEOF GROUT SEAL SPECIFICATION <br /> UC �FFF1 <br /> IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E i <br /> ❑MONITORING GROUT SEAL PUMPED:El Y- CONCRETE PEDESTAL BY DRILLER r No g IOU <br /> APPROX.OEM LOCKING CHESTER SOX/STOVE PPE S <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WrTH BM JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULER AND <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 PERArT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUBCONTRACTING WONATURE CERTIFIES <br /> THE FOLLOWING: 'I ERTIFY THAT IN THE IRIFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORXMAN'S COMPENSATION LAWS OF <br /> CAUFORNtA." THE NT MUST CALL UItS I 1 ADVANCE FOR ALL II 11—INS/ ]Z AT 12001 448-1423.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> SIVrW X Tits 1//i(!.- L-�/L� <br /> KDT IDIen to ScMel 6eaN 'to ff <br /> 1.NAMES OF ST ETB OR ROADS NEAREST TO OR BOUNDING T PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GASI <br /> NG DIMENSIONS AND NORTH DIRECTION. EXPAN810N OF SEWAGE DISPOSAL BYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6.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 /> C� <br /> ,. <br /> �. <br /> >\... 1% <br /> CH <br /> jfoE�rAG.H <br /> ..... <br /> k, <br /> I <br /> DEPARTMENT USE ONLY ' <br /> pIi tion Accepted By �-g <br /> Date <br /> —1 mpattien BY D•N (/ pipnp Inpectbn By <br /> huction InPectlon By <br /> mbltl: <br /> ACCOUNTING ONLY: ALD/ FACT <br /> RE CODES FEE INFO AMOUNT REMITTED C/IEc AIN RECHVED SY DATE P@NOT/SOMCE REQUEST NUFA SER INVOICE <br /> �fC� <br /> so o lY <br />