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?LICATION FOR WELL/PUMP PERM'" _ <br /> S; QUIN COUNTY PUBLIC HEALTH Sl <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> kP (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> lCOM <br /> xfe <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ICTAND/Oq INSTALL THE WORK DESCRIBED, THIS APPLICATION 16 MADE IN COMPLIANCE WrTIt SAN <br /> JOAQUIN COUNTY DEVELOPMEN--,T{`T--RUE, CHAPTER 9-1116.3/AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR AM# INTTTL'�Y'CS+ CO�J �AV Dr 5 v, ` LQ n QqK Cm <br /> OWNENB NAME Af ROYIAI*^ JLC�. C�J1M\,Y PARCEL BIZEIANI <br /> 11 ADDRESS 3SIO RbQ- .!-% gIIA p '/1 <br /> CONTRACTOR SLNI"1"L1 L .A-cyuok1 ren y� L, y+y�� LUYL ( PHONE # { 52 - 32, (� (3 <br /> ,L ADDRESS 17.�0 �I+W 1qT 4Y" l-L UCF s-lv $ U 1 7 59 • ZZZ- 1 <br /> SUB CONTRACTOR U VJ ,yJf���L 'n. 6"y sI .n -] ' Jy ^gip PHONE / �{ I� <br /> MDRE68 ` J , 1C�O V\ $ � Lice CL r U PHONE O 3-7I4V <br /> TYPE OF WELL/PUMP• (T NEW WELL ❑ REPLACEMENT WELL <br /> ❑ INSTALLATIONMONITORING WELL A ALAI 3 ❑ OTHER <br /> ❑ WEIt SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR <br /> DEPTH PUMP fiET <br /> RVPE OF PUMP) <br /> 11 New ElRenell N.P. ❑ VAPOR EXTRACTION WELL jr <br /> Fi. J <br /> ❑ DVT-OF6ERVICE WELL ❑ GEOPHYSICAL- Finn WATER LEVEL WELL P O <br /> ❑ DESTRUCTION: ❑ SOIL BORING <br /> S <br /> INTENpEO USE TYPE OF WELL <br /> ❑ CONSTRUCTIONCAVATICATIOND <br /> INDUSTRIAL ❑ OPEN BOTTOM <br /> ❑ COMESTICRNeVATE 13 GRAVEL PAI TYPE <br /> OF WELL EXCAVATION lv — �AL.L1 A <br /> DIA, OF CONDUCTOR CASINO <br /> ❑ MBLIC/MUNICIPAL ❑ DnIVEN TYPE OF CASINO/6TFELIPVc C � `• DIA. OF WELL CASINO Z � LNvi�L O <br /> DEPTH OF GROUT SEAL 7%Z SPECIFICATION SC O <br /> ❑ IRRIGATION/AO ❑ OTHEfl GROUT SEAL INSTALLED BY P "•,r <br /> Y„ <br /> A R <br /> MONITOPINO GROW BEAL PUMPED: wI] GPOW BRAND NAME BLtA� N� UL�� <br /> ARMOR. pERN <br /> CONCRETE PEDESTAL BY DRILLER: ya.❑ W N. S <br /> PROPOSED CONs"Lo10NLNSLUNG METHOD: MUD ROTARY LOCKING CHESTER BO%/STOVEPLPE <br /> AIR ROTARY AVCER_� S <br /> CABLE OTHER <br /> 1 <br /> REGULATIONS <br /> CERTIFY THAT I JOA PREPARED THIS APFIICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY OP,OINANCEe, STATE IAWB, AND gULLe ANO <br /> REGUUTION9 OF THE SAN JOAQUIN COVNrv, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING; •1 CERTIFY THAT IN THE PENpgMANCE OF THE WOR( FOq WHICH <br /> THIS PERMIT 18186UED, I8IFY THAT EMPLOYTHE PERSON <br /> PERFORMANCE <br /> E WOR%MAN'SCOMPEFISATIOR LAWS OF CALIFORNIA." COWMCTOR'e NINNG OqB WCAMANC OF HE "I% CERTIFIER <br /> THE FOLLOWING; • I CERTIFY THAT IN AM PERFORMANCE V THE WORD FOR WHICH THIS PERMIT IS ISSUED, I BHA LL EMPLOY PERSONS SUBJECT TO WORKMAN'S TING SI N SIGNATURE <br /> ATION LAWS OF <br /> III x CAUFORNIq,/•/T�HE�APPLICANT MUST JCA/LL ZA HOURS IN ADVANCE FOR ALL REQUIRE IT <br /> INBPECTGNS AT 12001 gNJM E COMPLETE ONS SUB AT LOWER RK A N'S CO D. <br /> RgG <br /> V i9 _� Title_( n 04;d IY�a mn <�.:; Dna_ 7 <br /> PLOT PUN _ %WW <br /> 1 . NAMES OF STREETS O0. flOADB NEAREST TO OR BOUNDING THE McFERTy. eels - to <br /> ]. <br /> DIMENSIONED 2- OUTLINE OF O NES ANG MNGLOCAMENSIONN OF ALL AND O AND DIRECTION. <br /> 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROMSED <br /> STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAIL EXPANSIONION OF HEWAGE THINDISPFURL SYSTEMS. <br /> S. <br /> LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> ON THE PRO <br /> PENTY On ADJOINING PWPEIF Y, <br /> APvlleellen Ae.epleA BY <br /> S SYI L�✓L �- �y/-{/�/=�(.-�¢,[''/ I Dole Ara. <br /> OrvN Inegeel on By �J 2 d -' Irvvxtlon I I •�r� G c <br /> Ow.tnwBen ImnecUvn Br / l ev. L- J note <br /> Comment.: net@ <br /> ACCOUNTING ONLY: ARMr <br /> FACT <br /> PE CODES FEE INFO OUNTREALITTED CHECKF/CASH RECEIVED BY DATE <br /> D PERMITISEILVICE REQUEST NLNIS9L INVOICE <br /> L ct 3 f e D <br /> PUD. Health Sew. - Envlro, 173 (1/97) <br />