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APPLICATION FOR WELLJPUMP 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 1 YEAR FROM DATE ISSUED <br /> ICemplete In Trfplfcttel <br /> APPLICATION IB HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WTT11 BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 1155^3�A►J/Q THE 8 ND RDS OF BAN JOAQUIN COU 'VB C HEALTH BERM E8,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN6 /��( C(f`I L/\ �G� CITY PARCEL SIZE/APN/ <br /> OWNER'S NAME AD0fIFS PRONE I <br /> CONTRACTOR ADDRESS /¢ UC/_lrpj PIONE/ 7z77"3��� <br /> SUS CONTRACTOR ADDRESS UCI PRONE <br /> TYPE OF WELL/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLI J <br /> ❑New ,❑nw w, H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL O <br /> HYPE OF PUMP) <br /> ////��� (X� ❑ OUT-0E-SERVICE WELL 11 GEOPHYSICAL WELL/ ❑ SOIL BORING S <br /> ESTRUCTION: CJ`s` — ` kao Tom' <br /> 14 <br /> INTENDED USE TYPE OF WEIR CONSTRUCTION SPECIFICATIONS it <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR VASINO O <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASINO D <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> Cl MOMTORINO GROUT SEAL PUMPED: ❑Yee ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y- ❑Ne S <br /> APPROX.DEPT" LOCKING CHESTER BOX/STOVE RPE 5 <br /> PROPOSED CONITAUCT10NA7FRWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S 8143NATUM CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE Of TINE WOR(FOR WHICH <br /> THIS PERMIT IB 188V ,1 814ALL NOT EMPLOY PER90NO SUBJECT TO WORKMAN'{COMPEN6AT10N LAWS OF CALIFORNIA.' CONTRACTOR'S MFING OR SU"ONTRACTING MONATURE CERTIFIES <br /> THE FOLLOWING: CERTIFY THAT M E PERFORM E OF THE WORK FOR WHICH TH RMIT IB ISSUED,18HALL EMPLOY PERSONS SUBJECT TO WORK MAN'6 COMPENSATION LAWS OF <br /> CAUFORMA.' T A A�CANTST C 21 N ADVANCE FOR ALL REQUIRED Mt TWINS AT 12001499-2423. COMFU-TE DRAWING AT LOWER AREA DED. <br /> Slgned X Tltle Det• <br /> PLOT FLAN 113—le 9o1e1 S—Ie 'to <br /> 1. NAMES OF STREETS OR 8 NEAREST TO OR BOUNDINO THE PROPERTY, 6. LOCATION OF HOUSE BEWAGE DISPOSAL SYSTEM OR PrtOPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVNIG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WrTMN RADNS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ... i �. <br /> 70 .............. <br /> ,. .. .<..... .. <br /> nese <br /> �jEC p 11999 <br /> hL VAL- T1-� <br /> �yv�rlOi�ty <br /> p�HP�Ai�r I SER <br /> ,� v <br /> .. ...... .. ... ....: .. ..... �1. i <br /> Y w D <br /> DEG 2- 1CM <br /> IC iFA1r <br /> D T <br /> USE ONLY ( Ul D <br /> Applle.tl.n Am ted 8Y L Dete I 1 A— <br /> 0'.N I-p-0—By Det. rLnP 1-0-0—By //� Del• <br /> D-Inxtl..lmvwtl n BY Oet._/ <br /> Cemmd.t.: <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED I CHEC /CA6H RECDVED Sy DATE PERMIT/6EAVICE REGLIEST NUMBER INVOICE <br />