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0 <br /> APPLICATION FOR VIELLIPUMP PERMIT <br /> >,rSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICtr— <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 988,304 EAST WEBER AVENUE, STOCKTON. CA 95201388 <br /> (209) 488-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TrlpReerol <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANIMA INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALLTT04SEERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSANI APNE / ✓ �. G r el(Gl f (�(/GL CITY LJ� ! V r, PARCEL SQUAMI <br /> -ff43(I c csap� <br /> OWNER'S NAME .2W,� ADDRESS slz'DLuc7tr.'l'. LH Ef C, 9S (1 PHONE '/ p•F <br /> CONTRACTOR S CL ic"" � 6m 1h G r ADDRESS e23&E T/✓I jtV4,,yt LICE 512 G S BONE/ �I&T-6 /t)— <br /> PUB CONTRACTOR ADDRESS / IICI RHONE S <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL E ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL E J <br /> RYPE OF PUMP) 11N.0 Pap.' H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O <br /> /� P— Olt-OF SERVICE WELL ❑ GEOPHYSICAL WELL E ❑ SOIL BONNG ,� I g <br /> DESTRUCTION: l {�QA"JV, (7Y\ QFJ,i✓c7 2 f 1 }ayyl :i - b t I ( � f W 11 N. 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONBPECIFICATIONG 1J�'w4 IUU���L.WWI�A% <br /> ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION VIA.OF CONDUCTOR CASING <br /> •F O <br /> ❑ DOMESTICNRIVATE 11 GRAVEL PACK/SIZE TYPE OF CASING/STFELHPVC DIA.OF WELL CASINO <br /> ❑ PUBLC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME MA E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Ys (IN. CONCRETE PEDESTAL BY DRIILLER:❑Y- (IN. S <br /> APPROX.DEPTH LOCKING CHEBTEn BOX/eTOVE RPE y. <br /> PROPOSED CONSTRUCTIONIDIILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY 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 AOENT'e SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THISP UED,I SH ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION HAWS OF CAUFORNIA.• CONTMCTOR'B HIRING OR 6U6-CONTRACTING SIGNATURE CERTIFIES <br /> THF LLOWINO: CERTIFY THAT IN THE PERFORM ,ICE QE THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAU IA• THE P(RCANT MU CA 24M IN A ICE FOR ALL REOU NG,INSPPEECCTIRINN I AT 120e14SSJ423. COMPETE DRAINING AT LOWER AREA POND ��1 <br /> BIpm4 X TIS._-- /" T-a Li, D.I. -lW-9 <br /> POT PAN In.le SOY.1 Setl. •le <br /> 1. NAMES OF STREET"OR ROADS NEARS TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OB PROPOSE" <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIMCTION. EXPANSION OF$MADE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLNEB ANG LOCATION OF ALL EXISTINO AND PROPOSED S. LOCATION OF WELLS WtRN RADIUS OF ONE HUNDRED FIFTY PT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> D 't�° <br /> �l Do�� <br /> C �4`° B�, <br /> IhCOnr'yc.fi.dL <br /> y=�L-dLn� Wo- <br /> //�//fF'�� �_./�� DEPARTMENT USE ONLY <br /> Applro.Sen Ae wtW By_ }' / 1�IY L/ O.I. • L �' M.. <br /> OreuH Impee,ron By D.Is Pune Impeellen By D.R <br /> De.,nNlron Impmlron By <br /> D.I. <br /> Denim>4.: L O'De, M.+- f 1377-13-3 sr -ed 611 429pt05U10 dantV lafic1-) - PLV47a <br /> co <br /> ACCOUNTING ONLY: AIDS FACE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKEICASN I RECOVER BY DATE IBNBT/SERVICE REQUEST NUMBER INVOICE <br /> 35o1,D a - N.l b t 218 <br /> Pub.Health Sent.-Enviro.173(3/96) <br />