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• APPLICATION FOR WELLIPUMP PERMIT• <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 85201,988 <br /> (2091469-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED FILE COPY <br /> APPLICATION 18 HERE BY MAGE TO THE SARI JOApUN COUNTI'FOq A PERMIT TO CONmSTROCTIgNDv In TOR�N6igLL THE WORK DESCRIBED.THIS APPLICATION IB MAGE IN COMPLIANCE WRH BAN <br /> JOAQUIN COUNTY DEVELOPME CHIApT 9-111 ,3 THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL N <br /> JOB ADDRESSOR ANN. HEALTH <br /> Dq/IBGN, <br /> CITY 5 cktLrvl Z'37acits <br /> OWNER'S NAME iV/P/ O I !'; PARCEL BIIFJAM/ S�C�JG-C <br /> ApORf66 Y <br /> CONTRACTOR C ? y1 �i 1 L�� � 1�j1, G�✓ — RHONE F <br /> L� Z PE68�CGIGTI VL 1 �` LICJ ' !� <br /> BUB CONTRACTOR v C 1 ✓U VVl r—,(� tC.f� PNDNE I&a - �p S$k <br /> Cr.L gyp, as b� -'1 <br /> RHONE/4 S-IS /) <br /> -vpc OF WEL4T11MP• ❑ NEW WELL ❑ REPLACEMENT WELL s(' K P'—'I Tj <br /> C7 MONITOMNO cY I ❑ OTHER <br /> ❑ INSTALLATION Cl WELL SYSTEM REPAIR ���0 <br /> ❑ CROBBC SET REPAIR VP,3S ❑ VAPOR EXTRACTION WELL/ <br /> ❑N.❑P..IT H.P. DEPTH PIMP SETFT. <br /> TYPE OF R1MP K (i S FAST WATER LEVEL <br /> ❑ <br /> DESTRUCTION: OUT-o"ERVICE WELL ❑ GEOPHYSICAL WELL J ❑ O <br /> � BOIL BORING 8 <br /> IJ <br /> :N iENOEO USE TYPE OF WELL CON{TRUCDOM SPECIFICATION{ <br /> ❑ INDUSTRIAL ❑ PE BOTTOM <br /> �1 0 r McNT}e Fc7 DIA.OF WELL EXCAVATION N5q A <br /> -3 DOMESTIO/PRIVATE LPACX/gI C...,.-I �-L DIA.OF CONDUCTOR CASING Q <br /> TYPE OF CA61NG/STEEI�_ 4-11 SGheLI U ll e 4-V ORA-OF WELL CASING--- <br /> IllJ�11 PUBUC/MUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL ShcI1P W U-Ij� O,I <br /> :.J IRRIGATION/AG EJ OTHER _GROUT 6fAl INSTASPECIFICATON ``�� R <br /> LLED SY GROUT SRAM <br /> NAME I V L} VYI QVl fi <br /> 1. <br /> MONITORING SEAL PUMPER: NP E <br /> :.PPROX.OFITHS{V IILYV ZZT ' beep � Ys/ ((/!'CONCRETE PEDESTAL <br /> 5(491'L DESTAL BYI ORILLER: Y. ❑Na S <br /> 11 <br /> LOIXING CHESTER BOX/STOVE RPE L TTiC MCv'iI'� <br /> ' 0POaEp CON{TPIMTONIDNWNG METHOD: MUP z+ed D ROTARY AIR ROTANyAUGEfl I <br /> � S <br /> CABLE OTHER <br /> i HEPEBY CERTIFY THAT I HAVE PR1EpAPEp THIS APRICATION ANO THAT THE WOFK WRL BE GONE IN ACCOPpANCE WITH BAN JOAGUIN COUNTY OPDINANCEB,STATE UWH,AND RULES AND <br /> ' GULATIONS OF THE SAN JOAQUIN COUNTY, NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE ..... MANCE OF THE NON(FOL WHICH <br /> THE PERMIT Ig BSUED,I SHALL NOT EMPLOY PERSONS <br /> FORMACEOFSUBJECT TO WORGMR COMPPBHBATION LAWS OF CAUMMIA.- CONTRACTOR'S HIRING OR SUBCONTMCTINO SIGNATURE CERTIFIES <br /> 1 HE FOLLOWING: 'I PLICACERTIFY THAT IN THE PERFORMANCE OF THE WpNL FOq WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSON8 SUBJECT TO WORXMµ•{COMPp{ATION LAWS OF <br /> ".AUFORNIA.- TT,HE APPLICANT MUST CALL I4 IN ADVAN ICE,MR A`�EOUREO INSPECTIONS AT 12MI 4YJ4==, COMPLETE DRAWING AT LOWER AREA/PROVL)ED <br /> ;Inrvd x 'IA,�`—� WpI�G JnHs �_��Lj1�'P./� Vl <br /> U ROT FUN 10,w m Bull 6.i1. 'le <br /> NAMES OF STREETS OR ROADS NEAFEST TO OR SOUNOMO THE P110PPFTY. <br /> OUTLINE OF THE PROPERTY.GIVING AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYSIEI.1 Oq g QMSED <br /> ! DIMENSIONED OUTLINES AND LOCAnON OF ALL EXISTING AND PROPOSED EXPANSION OF BEWARE HINIVDISPOSAL IS OF O B. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALJLS, I. LOCATION OF WELLS WITHIN ,,PR OF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ApJOMING PROPERTY, <br /> j ....... .... ... ......6 <br /> .. T .. .d.......... <br /> r. _ , ..: .... <br /> ' OfPMTMpT USE ONLY <br /> p(Ocrtbn Aee.lnd BY "- - �—t��9 DbV �.. <br /> OrnN Irnpylyn BY Orta <br /> Pune l.PacBen By <br /> p.S <br /> O.mmlbn In.ywlyn BT ' <br /> A K5 ,Cotu <br /> "--OUNrNG ONLY: AID{ <br /> FACS <br /> PE COOFI FEE INFO AMOUNT RURITTEO GRECKIICAEN RECDVFD SY GATE <br /> PFIWHIT/SERVICE REQUEfT NWOM <br /> 0 INVOICE <br /> 0/ ��, Z <br />