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APPLICATION FOR WELL/PUMP PER <br /> S.-_'JOAQUIN COUNTY PUBLIC HEALTH SttiVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 1,)4 <br /> (209) 468-3420 ( ` {� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Trlplic&t&I <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1 11 5.3 AND THE STANDARDS Or SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> gWq <br /> JOB ADDRESS/OR A/PNN\�f ly V' L 2- l2- (,, CITY Lingle,leh PARCEL SIZE/APN/ <br /> OWNER'S NAME 1 ayvj ON ADDRESS J/'r IY(C. PHONE I<�JZ I- / <br /> CONTRACTOR /rro �4 ADDRESS UCI PHONE I <br /> SUBCONTRACTOR �P�vFvcti,.,� � (,L,.r� ADDRESS_Z3Ccx—L,% UClsru�e9 PHONE# <br /> TYPE OF WELLIPVMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ,/ 6 <br /> R VPE OF PVMPI <br /> ❑New 11Rep•Ir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ! <br /> -1 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ A SOIL BORING � ly '249n g <br /> LJ DESTRUCTION: G�,fec&,j c,- �OYLL�Lr S I� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 [� <br /> ❑ DOMESTICRYIIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO O ' C, <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION �) ) IT <br /> ❑ C (�(Y- <br /> IRRIGA7ION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Ys [IN. CONCRETE PEDESTAL BY DRILLER:❑Vee ❑No S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIOWDrtlIUNO METHOD: MUD ROTARY AIR ROTARY AUGER _ CABLE OTHER <br /> I HE9FBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND T14AT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULAT F THE BAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THI RMIT IS 1S EO,I SI/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S AIRING OR SUR-CONTRACTING SIGNATURE CERTIFIES <br /> THQ FOLLOWING; I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,(SHALL EMPLOY{'ERSONB SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' INE PPUC ANT MU T C LL 2 HO IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(2001488-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> GIC-A X TIUw_ Z 9_7: <br /> .Y Bf•• rrt• w <br /> 20 <br /> x h <br /> I1 JV Ar- ATr 1v <br /> . ^ O <br /> 12 <br /> o <br /> • 11O AC. q�� <br /> A Q.J e A.- h Y I4 <br /> T 71.1 KAI S U /' I <br /> C <br /> I11� o l E. l wj -2- <br /> It �e <br /> 9 <br /> ,sem C)9!-© <br /> ^n DEPARTMENT USE ONLY <br />