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APPLICATION FOR WELLIPUMP PERMIT <br /> L SAN JOAQUIN COUNTY PUBLIC HEALTH SE6,_.-fS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 388, 904 EAST WEBER AVENUE, STOCKTON. CA 95201388 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplea In TriplicatB) <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN/ +/S- a CITY^_ S7-,e*/On1 PARCEL SIZE/APN/ <br /> OWNER'S NAME k ADDRESS YO /fQ,C ��y ,jYQAr) ,G ~,u PHONE 0&12)15(2-8(eff <br /> CONTRACTOR ADd1E68a/LH�faD � �ilr/•O .QQ1C! �1074� PHONE!(p///(eei..�L.�/�/,� <br /> SUB CONTRACTOR Ba <br /> Hr/ /QlCeI f,,ourw.rfpN ;r ADDRESS yj'7V 04W0,04t Llf�'Sft;Ai ,1'x1/13— PHONE EL/Ii7��'/1/dI <br /> /1 <br /> TYPE OF WEUJMMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> (TYPE OF PUMP) 11 Nsx 11 Repair H.P, DEPTH RUMP SET—FT. I FIRST WATER LEVEL O <br /> ❑ OUT-OF-SERVICE WELL .1../.—❑ G'EOPHAgYSIICAL�MUL 0 �1,, ❑ SOIL BOOJRI�NJG,.. 8 <br /> DESTRUCTION:_ .�p(B!s/J�4/k,PT/ /J'I/74/i[v�WL(�/ 14, /� ///[J IZ CN15C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 5 A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/RVVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEIJPVC DIA.OF WELL CASING O <br /> ❑ PUBUCRAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PIMPED: ii Y. ❑No CONCRETEPEDESTALIP(DRILLENOY. [IN. S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S <br /> PROPOSED CONSTRUCT10N/DmLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEAERY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH GAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES MD <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SXPNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPET/SAT,N LAWS OF <br /> CALIFORNIA. THE APPLICANT MUST CALL 24 HOURSIN ADVANCE FOR ALL REOUNIED INSRA:TONS AT IM)rlM 4BBJ422. COMPLETE DRAWINO AT LOWER AREA PROVIDED. <br /> elantl X &�,- Title_ /a1� Dtte <br /> ROT PLAN WtttY to eoeiol Sole / 'to 'yo r <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PSOMSM <br /> 2. OUTLINE OF THE PIOPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE 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 WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 6,' TYLw-Il <br /> � lac <br /> a tyeW-�3 <br /> k <br /> 1)_4rA' / <br /> L I TLs�Rroc <br /> TAeYvas '_ <br /> DEPARTMENT USE ONLY / <br /> Application AccWIl By D.I. �' / A,. <br /> Grout impoollon By Ott. Pump Impaction By pate <br /> D.mtruetlon Impaction BY Det. <br /> cc; mM nR: '1l14352- <br /> ACCOUNTING <br /> 1143S2ACCOUNTING ONLY: AID! FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC"MASH RECEIVED BY DATE PBIMITISERVICE REQUEST NUMBER INVOICE <br /> 35u� a b35� 5 •� � � I2 <br />