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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVO <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201380 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Comp1F(E In TrolkALB) <br /> APPLICATION IS HEM BY MADE TO THE 64M JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.MISAPPLICATION I6 MADE IN COMPLIANCE WHIZ SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF BAN/JOAQUIN COUNTY/PUB"LIC�14EALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODRESSMR APNF 1145 —C0L3�—��D�l�e �2'T0—L� to, *n4-z,1 4 Y CITY Sf-DC- 6- X <br /> O"IfIll NAME �,E�I S 1/lll�TV 1 (CiY1%1/1 G(� ADDRESS �J c '/ � 1 PARCEL 91ZE/APN/ <br /> CONTRACTOR CN'/YI `II J'•CD _5 �7.. I�F�ZDI}'T� PHONED` <br /> C 1 ` ADDRESS 'C rr NmeI Ip UCI PHO N Eg2b-0n2-12- <br /> sum <br /> -12'j <br /> SUBCONTRACTOR JQGJ rLLyyN �XID IFS (M+ LN L. ADDRESSZ3(1S W/14Aq v(l ucx-: IZZGB PHONE# <br /> TYPE OF WELL SUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL A I <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J <br /> ❑New❑Re6e1, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0, <br /> (TYPE OF PIMP + — <br /> ❑ OUT-0R SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION4 oI1 <br /> C2 DP 8 WCU A.OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEI/PVC DIA.OF WELL CASINO I H PDL D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 0 ' F SPECIFICATION L A <br /> ❑ IRRtGATION/AG ❑OTHER GROUT SEAL INSTALLED�8 �P GROW BRAND NAME N E <br /> ❑ MONITORING # e # GROUT SEAL PUMPER: 19 Y.e ❑No CONCRETE PEDESTAL BY DRLLER:❑Yw [IN. S <br /> APPROX.DEPTH 1S — J+O LOCKING CHESTER BOXBTOVE PPE �" S <br /> PROPOSED CONSTIIUCHONIDRRUNG METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER jrct�- PL{,y"'L. <br /> yw.alSlP' D <br /> 1 HEREBY CERTIFY T14AT I IIAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TIIE WOR(FOR WMICH <br /> THIS PERMIT 16 ISSUED.I 864ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENFATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FO IM-.! 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS BUBJFCT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIF PENIA.- TH ApPIICANT M fT C LL 24 HOl •I DVANCE FOR ALL REQUIRED INSPECTIONS AT ROS1,44a422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> BIF,w1X Tltl. �l 1 COS /l-2— <br /> ROT PAN In'.le Saw.)Seale 'to <br /> i. NAMES OF STREETS OR ROADS NEA TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING MINCNS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN FAMUB OF ONE HUNOND FIFTY P. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PAMS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY <br /> i 97 <br /> AFFBe•Ilan Ae.ePted By <br /> G,e6R I—Poo\loo By Dae Pane Imnee9en By 0•\. <br /> Deeln�Rlen Imnectlan er De\e <br /> cmn�nsae: <br /> ACCOUNTING ONLY: moo FAC# <br /> FE CODES FEE INFO AMOUNT REMITTED CHECKIICAAN RECOvjp BY DATE A PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 3 <br /> Pub.Heafth Saw.-Enviro.173(3/96) <br />