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APPLICATION FOR WELL./PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468420 <br /> - - N09•0EFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> ICEmplate M TripOaul <br /> APPLICATION 19 HEM BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOAR INSTALL THE WOR( DESCRIBED. 11119 APPLICATION i MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9. 11/,115.3 AND THE STANDARDS OF SAN "AMIN COUNTY MBUC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. -/ <br /> JOB ADORESAMP! AMS R1 F7Li' r �Iou/tr JLir rai/1' et4p � (? � cITY .�1 DV&/ 6y \ /y ,/(�,� FABc��j�BJtjEIAPNI0Z:!2/ �/ 7-0 - 0� / <br /> L/�L✓�� WNER' NAME / C STM T -f ULIDS (�//VYI ''1,4L1 ADDRESS U ' �V/� . ,40 .4A4 Awn yVT PIIONEI / /--� . CJyZ. t/&9S <br /> -41 G. ADDRE883/' `Y 1a /j DE' V L1c) �2�a SS�'� PNOHE 0 '71 +. 63/, 13/tO <br /> /.r�1D/NYt�B�Acs®R' L. Qy' l/AN !J f0 96,5Y� <br /> ADDRESS 1 99 S%'IO/' / 5 �l/C LL1 =# 6L MONE /D9. 7J=.37f <br /> �4 ev �0�57 rZ <br /> TYPE OF WELLARIMM ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONff0MM WELL l ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CP98S{ONNECT REPAIR ❑ VAPOR EXTRACTION Mug J <br /> ❑ Non ❑ IYPJ. H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O <br /> RTE OF PUMPL i / <br /> ❑ OUT-0FBERIOIO <br /> VE WELL ❑ GEOMVSAI l WELL ILY SOIL SOmNO _I 8 <br /> ❑ DESTRUCTION: , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / �/ A <br /> ❑ ENMITY MAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO p <br /> ❑ DOME9TIOARUVATE ❑ GRAVEL PACK/BRE TYPE OF CAMNGISTEEfAVC DIA. OF WELL CASING p <br /> ❑ MOUC/MUMICIPAL ❑ Drown DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIOATIONIAO ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING I OROUT SEAL PUMPED: ❑ Yet ❑ No CONCRETE PEDESTAL BV ORLLER: ❑ V. ❑ NO S <br /> APPROX. OEPTH t'✓© LOCKING CHESTER BOX/STOVE RPE <br /> PROPOSED CONSTRUCTONAIOWMQ NUMB: MUD RDTARY AIR ROTARY AWER CABLE OTHERynw Fro <br /> I HEREBY CERTIFY THAT I IIAW PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH BAN JOAQUIN COUNTY ORGINAWEB. STATE LAWS, AND R S ANO <br /> MMIRATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S 91UNATUM CERTIFIES THE FOLLOWING: '1 CERYR V THAT IN THE PERIM MANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 19188UED. I SNALL NOT EMPLOY PERSONS "ACT TO WORKMAN'S COMPENSATION LAWS OF CALUMPSKA.' COMMCTOR'BHIRNGORBUBCDN TMMNATUMCERTIRES <br /> THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOM FOR WHICH THIS PERMIT IB ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA ' TNF A�p,pU��A�M,/M/y T/yamALLJ1� IIOIl1Y I{N,LWANCE FOR ALL REOURI®/INSP�ECTIORS T 13081 .4-i11]. COMPLETE OMVNNO AT LOWER AREA PROVIDED, /l <br /> StorwtlX I _ " _/ . CLQ// / " � TIN. %�.r'I/>r 6 D.t.4/40/f <br /> 7 7 I/ ;v1.I <br /> ROT MN RI..W to 801110 Ba.IS�_ - to 30 <br /> I . NAMES OF STREETS OR SCADS NEAREST TO OR BOUNCING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DUPOSILL SYSTEM OR PROMSED <br /> 3. OURU E OF THE PROPEMY, ONNEG DIMENSIONS AND NORTH DISSECTION. 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 FT. <br /> STRUCTURES. INCLUDING COVERED AREAS SUCH AS PATHS. DRIVEWAY9. AND WALKS. ON THE PROPEREY OR ADJOINMO PPIORRTY. <br /> / <br /> App11..Ilom App«UM BYM .T OOMTMENT USE ONLY Oats <br /> T( <br /> G.«A m.p«nen By ��` D.t. w o impeop D BY o L Mr <br /> p..OwUen Imp«tlen <br /> By Oats <br /> ACCOUNTING ONLY: AIDS FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECS ASN RECEIVED BY DATE PBpGTISEAVICE REQUEST NUMBER INVOICE <br /> > c <br /> Pub Health Sam. - Enviro. 173 (1197) <br />