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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> LL- SIU 61 �-OS,04 00 (4-,(2('g) 468-3420 <br /> ISOC-REFUNDABLE PERLUT EXPIRES 1 YEAR FROU DATE ISSUED <br /> Omplete he TrIpUestal <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODRE98/OR((A��PH,,f.�,, f�1� ) t Ctry_CLQ J PARCEL SIZE/APNf n <br /> OWNER'S NAME,�Jy I A P/t'T[1�1A"� J„.,� Q ADDRESS </I/ g 1.1 PHONE f Il/Z <br /> CONTRACTOR V ADMOS23L (,( jatj)A_" LOCO PHONEfA66-87iZ <br /> RUB CONTRACTOR ADDRESS LIC# PHONE f <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER , <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROBB-COTN£CT REPAIR ❑ VAPOR EXTRACTION WELL f <br /> 13Naw 13Repair H.P, DEPTH PUMP SET FT. FIRST WATER LEVET. 0 <br /> RYPE OF PUMPI <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLf , SOIL BORING <br /> 13 DESTRUCTION-: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS /�. A <br /> ❑ INDUSTRIAL ❑OPEN Sor7OM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO / ) D <br /> ❑ DOMESTMIPRBVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASINO I I 7X 0 <br /> ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION n <br /> ❑y IRIBOATIONIAG 1:1 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> CI MONITORING �j GROUT REAL PUMPED: ❑Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑Y» ❑Na S <br /> APPROX.DEPTH Q} LOCKING CHESTER BOXISTOVE RPE S <br /> PROPOSED CONSTRUCTIORMNLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HMBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WINCH <br /> THIS PERMIT IR ISSUED,1 BHA OY PSUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIER <br /> TRIS FOLLOWI t CERT THAT M:PET-9nRFE OF THE WORK FOR WHICH THIS PERMIT IR ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORNM T APPLIC NT LL 24 HO IN AIYVANCS FOR ALL REQUIRED LNS►ECMNS AT 12081 40044". COMPLETE DRAWING AT LOWER AREA D M. <br /> SiOncd X Tilts-- Date CIC! <br /> PLOT PLAN O&W to Social Seale •to <br /> 1. NAMES OF STREETS OR ROAD NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTNO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,WILUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINMO PROPERTY. <br /> T <br /> l -D.� L`T P!, <br /> G I �!G <br /> 1 <br /> IL - ..­ J <br /> L Wei ................. ............................... <br /> DEPARTMENT USE ONLY G Q� <br /> APPReetlen Accepted BY Date <br /> OmA Impaction ST Dctc Pump tncpectlon BY II'' r Q/Oate <br /> Oact miles Impaction BY �" !`�- y Date �1� l'A79 <br /> r <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO AMOUNT REMITTED Q; ICA811 RECEIVED BY DATE PEANNTISEAVICE REQUEST NUAIBEIU INVOICE <br /> 3s of 9, oa lS��v yl.*-yl4 Isyy <br /> Pub Health Serv.-Enviro,173(1197) <br />