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• APPLICATION FOR WELLIPUMP PERMIP <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 95201388 <br /> (209) 4583420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> APFIJCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERM?TO CONSTRUCT ANDPOR INSTALL THE WORK DESCRIBED.THIS APRJCATION IS MADE IN COMFIIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TIRE,CHAPTER9-11115.3 AND THE STANDARDS OOF1 SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOBAQDRESSIORAFHL CA�ILLIn 1/^T 12-1-12-1- 12HE0I0A4 'A-; / CRY TVIAcq A .(J /� PARCEL SUWAPNI �Lt�f <br /> OWNER'S NAME /�J e�NI✓It, Ft9epdls ADDRESS 24.101 M QMa /11 l i(!✓' tf ✓^,Js. PHONE I4 AGI o <br /> CONTRACTOR Ci YIIk oy'd vic =vtr AGORESS MCA lYI Mg <, Auc,,20624! FHONEI.O[Q 4,8,.; Q7-1; <br /> SUB CONTRACTOR Ip ADDRESS LIC, PHONE i <br /> TYPEOFWEL./PUMP. LCI NEW WELL ❑ REPLACEMENT WELL ❑ MONTONNG WELL& ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS{ONNECT REPAIR ❑ VAPOR EXTRACTION WELL I- <br /> 0 N_1:1 Rap <br /> ❑New❑Rap Jr H.P. DEPTH PUMP SET-FT. FiR WATER LEVEL 0 <br /> TYPE OF PUMP <br /> ❑ OUTM) SERVICE WELL ❑ GEOPHYSICAL WELL i ❑ SOIL BARING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION'R I-nMiaHi G INDUSTRIAL 1❑OPEN BOTTOM DIA OF WELL EXCAVATION / RI/ DIA.OF CONDUCTOR CASING D <br /> ❑ DOME /P <br /> STICRIVATE CIp GRAVELPACKSQEYPE <br /> ��l2 TOFCASINGSTFE!/WCSCNCI'I.LC -FOP✓C DIA.OF WELL CASING �" D <br /> ❑ PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEA_ ^/� SPECIFICATION R <br /> ❑ IRRIGATIONJAG ❑OTHER GROUT SEAL INSTAL. BY' llNl II=In GROUT BRAND NAME IF <br /> ❑ MONITORING GROUT SEAL POMFEQ: BY_ 0 N CONCRETE PEDESi AL SY DHILLPE❑Ynt [INR $ <br /> APPIIOX DEPTH LOCKING CHESTER BOXISTOVE RPE y. <br /> PROMSE)CONATRIICTIONIDNWNG METHOD: MUD VOTARY AIR PATAM AUGER CABUt OTHER <br /> - <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PQUORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED.I SHALL NOT EMPLOYP£RSONS SUBJECTTO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR-SHIWNGORSUB ONTMCIWSIGNATURECERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMFLOY PERSONS SUBJECT TO WGRKMAN'S COMPENSATION LAWS OF <br /> CALIMMUL' APPUCAM ML4T K NO i-IN ADV//IAN/�//'/B�/B/QR ALL REQUIRED INSP/EECTIT�IONS AT DION 448 1=. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> SIBS X �NI //j� /I/K-�.' Y TI[le 1 J e©/©Q l S I <br /> wla <br /> PLOT LAN Drew to Sinal Sale 'to <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 OFTHE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY L� 2 <br /> ApPlloeGen Amp[etl BY / <br /> G,.IrwP c,rt BY Dne Pomp lmp n BY Dna <br /> Dsxruc[len Ir�Pecign Br wr. <br /> comm : <br /> ACCOUMTMO ONLY: aW FACS <br /> PE CODFl FFF INFO AMOUNT gFT11TTED CHFLU="H RECEIVED BY DATE PDWITpNMCE REOUILBT NUMBER INVOICE <br /> �PI<71 Cb IU{Z., S- <br />