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APPLICATION FOR WELUPUMP PERMIT <br /> SAirJAQUIN COUNTY PUBLIC HEALTH SE,.00ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS(HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A MMM TO CONSTTRUCTIA O/on INSTALL THE WOW DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMMENTT T"IT�LE•C�HHAA"ER 9'1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOBAODRESS/Ofl AFN# $l" �J(J!f'1-�U 4-We CITU Lr�n� / <br /> may,... ITY PARCEL SIZEIAPNF_/�A <br /> OWNER'S NAME._ //IV�f�� �JBU4(/r(( —���� �,�J ADDRESS�J AJT� / 4/�� l �yy,J/yJc/ <br /> �dIIr-QLI G�(/EL /JJPHDNE. ) / <br /> CONTRACTOR N l/E�' SIL/ ADDRESS � ry• ((J�G�Qr1/ � ONE/ �'/OY�{� <br /> SUBCONTRACTOR ADORERS 6 <br /> lKI RHONE# <br /> TYPE OF WELUPUMP' ❑ NEW WELL ❑ IIEFLACEMETIT WELL ❑ MONITORING WELL# ❑ OTHEfl <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CDOSBCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ,/ <br /> 11 New 11 Repair N.P. DEPTH UMP SET Ff. <br /> RYPE OF UMP —_ FIRST WATER LEVE/L q O <br /> ❑ OUFOF-SERVICE WELL ❑ GEOPHYSICAL WELL I SOIL BORING <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPELL CONSTRUCTION SPECIFICATIONRqq r J A <br /> 11INDUSTRIAL ❑OPEN BOTTOM CIA.OF WELL EXCAVATION OP DIA.OF CONCUCTORCASINQ ��,FFy//111 D <br /> ❑ DOMESTIC"VATE 11 GRAVEL PACK/BRE TYPE OF CASINO/STEEUPVC AA# DIA.OF WELL CASINO N D <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL A61 RRECIFICATON R <br /> F❑y IRAGATION/AO ❑OTHER GROUT REAL INSTALLED BY r��yw W/F"F/"1 ODOVf BRAND NAME y E <br /> .CF MONITORING /� GROUT SEAL PUMPED: [IV. O Ne CONCRETE PEDESTAL BY ORIM R:❑Y. RNe 5 <br /> APFROX.OMH LOCKING CHESTER BOXISTOVE PPF16� y. <br /> RIOMSED CONSTRUCTIONRNSWNG METHOD: MUD BOTANY AIR ROTARY AUGER CABLE OTHER/ <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK 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 AGENT'S SIGNATURE CERTIFIEB THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORM ICE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' C T ALL ZA MUM IN ADVANCE FOR ALL REQUIRED <br /> �INSSPIC�TIOON'S�AATTL/12(HRA4004M22. CO <br /> PtETE DRAW <br /> ING AT LOWER AREA PIOMP <br /> RIPmE X <br /> PLOT RRLN Phew le SeNFI Seaie •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPLRTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL RYBTEM OR ROIOSEO <br /> Z. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NOW"DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLNF.R ANO LOCATION OF ALL EXISTING AND PROPOSED R. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAU(S. ON THE PRORHTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY ......... .,._-� ... _. .... _...._...._... <br /> ApFneelbn Aeaepled BY__ M/LI L O.1• �Ar.. <br /> Grep1 Imp.Hbn By One Pvnp Imp.nen By �1� OKe <br /> D.N.�enen ImpevHlw•ar D.r. <br /> celnrnenre: <br /> ACCOUNTING ONLY: ADI FAC# <br /> PE COOKS FEE INFO AMOUNT REMITTED CHECIUVCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NOMREII INVOICE <br /> O <br /> Pub,Health Saw.-Enviro.173(1/97) <br />