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APPLICATION FOR WELL)PUMP PERMIT <br /> *N JOAQUIN COUNTY PUBLIC HEALTH SERYIC19 <br /> ENVIRONMENTAL <br /> WEBER <br /> HEALTH , ST ON <br /> P.O. BOX 988,304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 488.3420 <br /> NOR-REFUMOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompl4u In Tripl'wEtE) <br /> APPLICATION IS HESE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE MW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAT n 8-11�3 AND TH S�11A}Rp9 OF SAN JOAQUIN COUNTY IC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN# . 1 � tVV�L((�,,,Irk I Ilr` <br /> A � CITY PARCEL <br /> OWNEn'B NAME ✓( 1 G"� ` AOGRESS !L� 11 -y •J��UPHONE <br /> P O E# <br /> CONTRACTOR 11 RC1 L 'l�l '�` ADORERS(/CJ lhh �no !Y'n UCICST�T11�ONE I�YVb '�S� <br /> 6V8 CONTRACTOR Sw-Sv�CA 5A..1"Q.110 <br /> ADDRESS UC# _PHONE# <br /> TYPE OF WELVPIMP: NLL <br /> 11 REPLACEMENT WELL MDNFFORING WELL/ ❑ OTHER <br /> VIT�S../1}9TALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> .1—❑R«.Ir H.P. DEPTH PIMP BET_". FIRST WATER LEVEL 0 <br /> (TYPE OF PVMPI <br /> ❑ om-or SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BONNO S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION$ A <br /> ❑ INDUSTRIAL r❑.-O/OPEN BOTTOM DIA.OF WELL EXCAVATION I^ DIA.OF CONDUCTOR CASINO — I D <br /> ❑ DOMESTICR'NVATE LYOMVIEL PACKISUE "L IZ TYPE OF CASINO/STEELU'VC DIA.OF WELL CAGING �� 1 D <br /> ❑ PIIBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION y, R <br /> ❑ IR AMNIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> MONITONINO //11 GROUT SEAL PUMPED: ❑Yr Na CONCRETE PEDESTAL BY DRILLER: Yw ❑Ne 5 <br /> APPROX.DEPTH I J LOCKING CHESTER BOXISTOVE PIPE 6�' s <br /> PROPOSED CONSTRUCTIONNWLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AW��7 LL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REOUlATiO OFT SAN JO UIN COUNTY. HOAR EflS SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF 111E WORE(FOR WHICH <br /> THIS PERMI IS IB9U ,I SIIAL t PLOY PERK <br /> EP NS SU JS 0 PENSATIOM UWB OF CALIFORNIA.' CONTMCTOR'B HIPNQ Oq SVS-CONTMCTINO SIGNATURE CERTIFIES <br /> LLO NG: ETI AT 1 RIE PE ORMANC OFTHIS PERMIT IS ISSUED,1 SHALL PLOY PERSONS BUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> 1 THE CA T CA 2 UR$IN ADVAEO INSPECTION$AT IMM 4 J4 COMPLETE DMWING AT LOWER AREA PROVIDE x T N J I ZvL L'✓`�`lh� D.I. ) J 7/ !� <br /> {{ / <br /> not UM <br /> 1131.to%W.p ft.[. 1 'Re LLVV <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NO N DIRECTION. EXPANSION OF$$WADE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIx S. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> �xy <br /> L <br /> DEPARTMENT USE ONLY O' <br /> APPIb.Ilen A."Red BY ' a D.I. l lr DD A,.. <br /> OrB,A Imv«Ren BY 'L-�L p.1a t/ , 00 glmv In,P«Olen BY O.Is <br /> 0«em6en Imn«G/e/n/B�y I, , / Dae <br /> CemmerrlFl �/ R P✓��/�u� <br /> ACCOUNTING ONLY: AID# FACE <br /> PE C7 <br /> ODES FEE INFO AMOUNTREMITTED IEC !CASH RECEIVED BY BAT PFRMRISERVICE REQUEST NUMBER INVOICE <br /> of R " D It V9 <br />