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- -- ------------- .. ........ .. . - : - - . --- ------ - ------ <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES of <br /> ENV1RONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95 <br /> (209) 468,U20 <br /> NON-AfFUNDARE PERMIT EXPIRES I YEAR FROM DATE ISSUED qo� <br /> lCompleft In Tilpikstal <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAGUIN COUN'rY FOR APETMAFT TOCONSTRUC7 AND/OR INSTALL THE WORK DESCRIBED.Ting APPLICATION <br /> JOAQUINCOUNTY DEVELOPMENT TITLE.CHAFTERO.1115.3AND T AN MAGUIN COUNTY PUqM HF 18 MAM IN CO?F1.N.1 WITH SAN <br /> H1 I 7EANIDARDS OF I _ALI"SERIVICEIV,ENVIRONMENTAL HEALTH omqION_ <br /> JOS AIDORFEISIOR APNI fhjrl(-�dlI� CITY <br /> 9-3 1- L7-- <br /> o"Fn-9 NAME PP 60 r <br /> A too"Me 3 a SEY-, <br /> A Be <br /> COWLrPtACTOR_AL T-;�-p k Vkl DORE] <br /> A sd <br /> ..T.ACTO. 10 PHONE 5'c <br /> CUB CONTRACTOR ADIDRES. <br /> TYPE OF wEuipump. El ww WELL REPLACEMENT WM MONITORING WELL 014 IJ OTHER <br /> 0 INSTALLATION WELL SYSTEM REPAIR CROS%-CONNECT REPAIR 0 VAPOR EXTRACTION WELL I i <br /> (TYPE OF PUMP] IJ me—1:1 Ree.4, H.P._ DEPTH PUMP SET FT. "RST WATER LEVEL 0 <br /> 13 ovT-oF-cEnvw:E WELL 0 GEOPHYSICAL WELL 1 8011.BORING R <br /> DESTRUCTION- <br /> INTENDED USE TYPIE OF WELL CONGTRUC71ON SPECIRCATIONS A <br /> 0 INDUSTRIAL 0oPEm sorrom VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CAMN(I__ 0 <br /> 11 DOMF9-fICMMVATF 0ORAVEL PACXIaIZ TYPE OF CAGINGISTEnJPVC OIA-OF WELL CASINO <br /> 11 PUBLICIMUNICiPAL El om\'EN DEPT"OF GROUT SM SPECIMATIO <br /> E <br /> 1-1 MAIGATIONIAG OTHER OFOU'r SEAL INSTALLED BY—Zd-I GROUT BRAM N" <br /> Nf MONMORING GmUT SEAL PUMPED" SU yee 0 If. b�c "C7�PEDCST`AIL BY DRILLER:0 Yew pj�4. s <br /> APPROX.DEPTH In LOCKING CHESTER BOXINTOVE P" s <br /> PROPOSED CON11TRUCtIORMIRILLING METHODi MUD ROTARY AIR Flo VARY—AUGER CABLE—OTHER <br /> S HE'WBY CERTIPYTHAT I HAVE PREPARfO T1418 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOADVIN COUNTY ORDINANCES.STATE LAWS.AND FtU1LES AND <br /> "GULATIONEI OF THE SAN JOAOU1fN COUNTYL HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES T14C FOLLOWING:-1 CERTIFY THAT IN TMF PERFORMANCE OF THE WOM F40R VA-nCH <br /> THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERS10NS 19VBJECI TO WORPWAN'S COMPENSATION LAWS OF CAUFORNIA.* CONTFLACTOFV8 J-RMN13 on RUB-CONTRACT*M SMNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN ME PERFORMANCE OF THE WOFIK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS VU�UECjr To wonkmAK,s COPAP94NAnopi LAWS OF <br /> CAUFORI4IA.* T FA HDURG IN ADVANCE FOR ALL REQUIRIM lmsmtloms AT 12061440-3.423. COMPLETE DRAWING AT LOWER AMA P.90 <br /> .=y Tj".41A'o t - <br /> 14V 7 . - A41Y11144notr -A Dole <br /> PLOT"N 0—f.8-1.1 mi.— qa -Q <br /> 1. NAMES OF 11TREETIS Oft ROADO NEAMBT TO on WLNMNQ THE PROPERTY d. LOCATION OF HOUSE OEWA41C Diepo AL SYSTEM OR P"OPOSED <br /> 7. OUTLINE OF THE PROPERTY.OWING DIMENSIONS AND NORTH DMIECTPON. EXPANSION OF FEWAOF DISPOSAL dryogATEPAS. <br /> 3. DIMENSIONED OUTUNFe AND LQCATIOp4 OF ALL EXISTING Apo pNopOjrED <br /> STRUCTURES, 5. LOCATION OF WELLS wVTHIN ptAINUX OF ONE HUINORED FFTY FT. <br /> INCLUDING COVEM13 AREAS OUCH AS PATFOS,DRIVEWAYS,AND WALKS. ON THE PROPERY"Y OR ADJOINING PROFERTY. <br /> .................. .. ....... <br /> ----------- ..... <br /> t ...... .... ....... . <br /> ........................................................... <br /> Appg..IP.n Acootd By IDEPARTMENT UZIF ONLY 0-10?4140flf AFoo <br /> I—P�tl�By Otte PU-w don a Dim. <br /> By-- Dole -Mb <br /> 4 p It r <br /> m 10 &- isocip &"-- - <br /> AIDO FACS Iry <br /> —!f CODE& FEE INFO AMOUNT FtVWTTED_ CHIPCICIfICASH RECEIVED My DATE PERRIETINERVICE RROMT NW@GR INVOICE <br /> ld9pp— <br /> &2 <br /> 04 Z5 <br /> Pub.Health Serv.-Enviro. 173 (1197) <br />