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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) 468-3420 <br /> NOR REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICampiste N TripBeal■1 <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 9 1 115 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> JOB ADORIESSMA APNr �� C '_ R- t ���L ,s,r . 'c- , / CITY 'i•: r PARCEL SIZE/APNE '" ✓' �'I <br /> OWNER 9 NAME ADDRESS _ !� r^ ( r 4 I PHONE <br /> CONTRACTOR s r' ADORERS /f _ _ <br /> ar `'^1![ LICd' � ' P10NE/ ' rte(^� <br /> BUB CONTRACTOR 'y/ s' r + ~'{' ADDRESS / s f ti/LACI '71. { PHONE Il �tl <br /> TYPE DF_WELLIPUMP, ❑ NEW WELL ❑ REPLACEMENT WELL © MONITORING WELL 8 �� < ❑ OTIIER ` <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑New❑Repair H P DEPTH PUMP SET FT FIRST WATER LEVEL O <br /> [TYPE OF PUMPF <br /> ❑ OUT-OF SERVICE WELL ❑ OEOPIiyrlCAL WELL♦ ❑ SOIL BORING A <br /> ❑DESTRUCTION <br /> IN TFd1OED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA OF WELL EXCAVATION DIA OF CONDUCTOR CASINO w tr <br /> ❑ DOMEBTICIF'RfIVATE ❑GRAVEL PACKISIZE TYPE OF CA91NOI8TEELI1-VC DIA OF WELL CASINO tl <br /> ❑ PURUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IMOATIONIAG ❑OTHER OROIrr SEAL INSTALLED BY ' GROUT BRAND NAME E <br /> J <br /> © MONTOfaNO GROUT SEAL PUMPED 13Y- DNe CONCRETE PEDESTAL BY DRILLER ❑Yw ❑No 5 <br /> APPROX DEPTH LOCKING CHESTER SOXItTTOVE PIPE S <br /> �pROPOSFD CONSTRUCTIONiMLUNO METHOD MUD ROTARY AIR ROTARY AUGER ' CABLE OTHER <br /> 1 HV ERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR{WILL BE DONE IN ACCORDANCE WITH CAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULER AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY HOME OWNER OR LICENSED AGENT 8 81GNATURE CERTIFIES THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED I SHALL NOT EMPLOY PERSONS BURACT TO WORKMAN S COMPENSATION LAWS OF CAUFOFMA. CONTRACTOR 8 HIRING OR 110"ONTRACTING SIONATURE CERTIFIES <br /> THE FOLLOWING 'I CERTIFY THAT M THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED 1 SHALL EMPLOY PERSONS SUBJECT TO WOMMAN 4 COMPENSATION LAWS OF <br /> CALIFORNIA' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION*AT C2003409.3423 COMPLETE DRAWING AT LOWER AREA PROVIDED <br /> Signed X 'r `p--^i Title rr Date <br /> r` <br /> / PLOT PLAN Mk&W to Boalal seal* 'to <br /> I NAMES OF STREETS OR ROAD8 NEAREST TO OR BOUNDINQ 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 i <br /> 3 DIMENSIONED OUTURFS AND LOCATION OF ALL EXISTING AND PROPOSEO a LOCATION OF WELLS WTINITI RADRfs OF ONE HUNDRED FIFTY FT <br /> STRUCTURES INCLUDINOj COVERED AREAS SUCH AS PATI08,DRIVEWAYS,AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY <br /> I <br /> Q <br /> 11 <br /> N <br />