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API''f H.AIION I ON WEI1)PUhd•I LRMIT <br /> SAN JOAOIIIN COl1NfY Pl1BLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O,BOX 3kW,3kA EAST WEBER AVENUE,STOCKTON.CA 95201388 <br /> (205)460 3420 <br /> h0N HEtUNDAHLE PEHMIf tXPIHES 1 YEAR fNOM OATS ISSUED <br /> IcampIBTB In TTIpIkBEBI <br /> APPLICATION 18 HERE BY MADE TO TILE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRICT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE W1ITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8 11/1/5.3 AND <br /> /INE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION <br /> N.. <br /> JOB ADORESB/OR A(P,NI W dFti.Cl"C/G //L�L 'Ll/RLC •�A'j.�[fL/(��.1CITY��I- PARCEL SIZE/APN/ , (C2,p e5 <br /> -030 OWNER'8 NAME jVY 7 14CI AL� ""' ,ADDRESS-f <br /> � PHONE/ <br /> AoOREas L1CS XU170 PNONE I(sM S7v 39>iv <br /> MOR <br /> CONTOTvOr L-L .,L. (--L. <br /> SUB CONTRACTOR LC T C.f7 <br /> _F36c�_ ATN)11EB8 LIC/PHONE 4-Pl-S,T'$/ <br /> TYPE OF WE ❑NEW WELL ❑REPLACEMENT WEIL ❑MONO ORING WELL 1 ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL# J <br /> ❑N—❑P-1, H P DEPTH PIMP SET_FT. FIRST WATER LEVEL 0 <br /> (TYPE OF PUMP) <br /> ❑OUT OF SERVICE WE 11 ❑OEOPIYSICAI.WEIL I y.�BOIL SORNO a <br /> ❑DESTRUCTION— <br /> INTENDED USE TYPE OF WEU CONSTRUCTION SPECIFICATIONS A <br /> 11INDUSTRIAL ❑OPEN BOTTOM OIA.OF WELL EXCAVATION Z i DIA.OF CONDUCTOR CASINO D <br /> ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE_ TYPE OF CASINO/6TEEIJPVC DIA.OF WELL CASINO D <br /> ❑P)BUC/MUNICIPAL ❑URVEN DEPTH OF GROUT SEAL SPECIFICATION q <br /> ❑IRRIGATION/AG ❑OTMER GROUT SEAL INSTAIIED BY GROUT BRAND NAME 1 LT..,f.C+2� E <br /> ❑MONITORING / GROAT SEAL PIMPED:❑Yr [IN. CONCRETE PEDESTAL SY DRIVER:❑Yw ❑N. S <br /> APPROX.DEPTH t /OCKINO CHESTER BOXAHOVE REE / s <br /> PROPOSED CONSTRLICTOO NIDRILUNG METHOD: MUD ROTARY AIR ROT AMY AUGER CABLE OTHEq /'1L{ to <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TILE V40FW WN 1.BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AN <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. /TOME OWNER OR ILCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT 70 WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.'CONTRACTOR'S HINNO OR SUB COM RAC TING SIGNATURE CERT IFIE6 <br /> THE FOLLO 0: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SIIM!EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPE7/SATION LAWS OF <br /> CALIFORN THE APP LV}N UST C HOI0181N AWANC&101n Al.h.,.,w..au N�.^rS�L Non.Al 122")4Y.Hi1.CG/MPE)E ORAWINO AT(OWER AREA PROVIDED <br /> 81pr»d <br /> pLOd <br /> T PLAN I),—1.SW.1 Bee '1p <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF TILE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 3. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WAIKS. ON TILE PROPERTY OR ADJOINING PROPERTY. <br /> DEPART ENT USE ONLY <br /> ApPllc•don Accepted BY_ L� _:_-__ _ ___ _.Odd �'[�✓ '� / Arr <br /> G.D.1 IrnvecllDn BY /— DerePmpin.pacUo.l Be D•1• <br /> Ue•1ncGon In•pecllDn By __ ___ _ D•Ie <br /> COIi1Tm. <br /> ACCOUNTING ONLY: AID# fACI <br /> PE CODES FEE INFO AMOUNT REMITTED CHECILe ICASH RECEIVED■Y DATE VEAMIT/SERVICE REQUEST NUMBER INVOICE <br /> Z o � 13 50 �25 5 b l l(P 3 <br />