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SAPPLICATj qR WELL/PUMP PERMF`"� <br /> AQUIN COUNTY PUBLIC HEALTH SE' ES <br /> ENVIRONMENTAL HEALTH DIVISION ' <br /> 904 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468.9420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS HERE EL MAGE TO THE BAN JOAQUIN COUNTY D T A P A,O TO CONSTRUCT ANUIN INSTALL THE WORX DESCRIBED.THIS APPLICATION I8 MADE IN COMPLIANCE NRTH BAN <br /> JOAQUIN COUNTY R,By ADE T TITLE,CHAPTER 9 IONSTRU E ID DXR,INT,IpSNSTALL <br /> {,1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMEMAL HEALTH W VISION. <br /> JOB AODRE82/Oq APN#_ �� S <br /> S. N N a t P Y 5f, <br /> OWNEq'e NAME QbLCRY S Nc <br /> 30 A 4 I h CU N h '� f 222 r. f FM PARCEL SIZE APNI-- <br /> COMMCTOq_ ADDRESS `N,F tl�, O 9 p nFL <br /> FIS(. La.utrOti LM P4 F� 1 r. G� Fa PLIONEI p- pJf <br /> ADDDEBS LIC/ $(7 PH,,w o 36_ -4'45 63 <br /> '. <br /> BUD CONFMCTOq // <br /> A.DMBey Sl 399226 <br /> � UCP PHONE• <br /> TYPE OF WELL/PUMP, 13 NEW WELL ❑ REPLACEMENT WELL <br />( 13 INSTALLATION ❑ MONITORING WELL# 13 OTHER <br /> ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR <br /> ❑New❑RePA, H.P. 13 VAPOR EXTRACTION WELL <br /> RYPE OF PVMPI DEPTH PL/MP 8ET__PT. J <br /> FIRST WATER LEVEL _ <br /> ❑❑ <br /> DEBTfllK;T10N: OUT-OF12/.OIL <br /> WELL ❑ GEOPHYSICAL WELLS O BOLI BONNO D Y'D pe B <br /> INTENDED USE TYPE DF WELL <br /> ❑ INDUSTRIAL CONSTRUCTION SPECIFICATIONS <br /> ❑OPEN BOTTOM DIA.OF WELL EXCAVATION L) H A <br /> ❑ DOMESTICNRIVgTE ❑p VEL PACX/SIZE f Z DIA.OF CONDUCTOR CASINO <br /> K-/}U TYPE OFF GRINO/61 AL/PVC e- AI h DIA.OF WELL CASINO D <br /> ❑ P RIGATI UNICIPgL I:J URIVEN DEPTH OF pgOUT SEAL 1 b [3 d"rE•O L'M SPECIFICATION 0 <br /> ❑ <br /> MONITORING <br /> ❑OTHER R <br /> . GROUT BEAR.INSTALLED BY � L <br /> ❑ MONITORING - '- (S h �Pv,L OIMIR BRAND NAME E <br /> GROUT SEAL PUMPED: Yw [IN. CONCRETE PEDESTAL BY DRILLER:❑Yom [IN. 5 <br /> APPROX.DEPTH LOCKING CHESTED BOXRMOVE RPE <br /> PROPOSED CONSTRUCTIONAMMINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Cre D pro R S <br /> 1 HElEBY CERTIFY THAT I HAVE PREPAREO THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REOULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF TIIE WORD FOR MICH <br /> THIS PERMIT IB ISSUED,I WALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTMCTIM SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORNIA.' THE APPLICANT MUST CCAM 24 HOURS IN ADVANCE FOR ALL MODIFIED INSPECTION.SPL <br /> AT fhNn 4",!M2S. COMPLETE DRARE <br /> WING AT LOWER AA PROVIDED. <br /> 61PmUX •' �/UMLQ TIO. I1'Qh 1fiD.1. ✓ 1s /Jt <br /> PLOT PUN(D'.1.S W.I&.1.�L •ro <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P10POGED <br /> 2. OUTLINE OF THE PROPERTY,OMNO DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWADE DISPOSAL SYSTEMS. <br /> S. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING ANO PROPOSED S. LOCATION OF WELLS WITHIN RA1XUS4OF ONE HUNDRED FIFTY R. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRVEWAYS,AND WALK8. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> MAP <br /> ®'✓ �- <br /> DEPARTMENT USE ONLY <br /> `/x'� 9 <br /> ApPllvelbn Awwled By bel. E. • A... <br /> OreN Impwllen By D.l. PImP ImPmBen By Daa <br /> bmrn<San Im.wlbn BY - -: ..: _ _ .._.- ,. _ .`_ ``Dile <br /> I <br /> ACCOUNTING ONLY: AID# FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECDVED ST' DATE PERMITRE VACE REQUEST NUMBER INVOICE <br /> 3 6v6 <br /> Pub.Health Sew.-Enviro.173(1/97) <br />