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ii <br /> I <br /> APPLICATION FOR WELLIPUMP PERMIT i <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> i <br /> P 0 BOX 358,445 N.SAN JOAQUIN ST,STOCKTON,CA 95201.388 <br /> -c. {2091485.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATS ISSUE. <br /> (CcmPk11 In TrrplkBt.) <br /> APPLICATION IB HERE BY MADE TO THE BAN JOApIAN CGVNHV FOR A PERMIT TO CONSTRUCT ANOAR INSTALL THE WOR(DEWRNI D.T/EI6 APPVCATON I"MADE N COMPVANCE WITH <br /> BAN <br /> .00AOIIIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1116,3 AND THE STANDARDS OF SAN MAOUIN COUNTY PUBLIC <br /> .} _T •� HEAL�A ALIERNCEB.ENVIRONMENTAL FIEALTN DIVIbyFi <br /> JOB ADOgE9P,oR AF•Hr� (y CITY V t/rll PAAtEI1� PN'I�ITt � <br /> OVVNER'S NAME }-� �.�y� ADp0E86 JA <br /> CONTRACTOR 1r�. r,/v.'+-FV`1 C ADDRESS �... V ucr �: . <br /> elle CpNTRACTOR_y�. LL'll'l I: i 'HOW IF ,F-} 'E •7p, , <br /> ADDPE88 RI o LICAPHONE. Y E '�/ r•pl� <br /> I <br /> TYPEOF WELLAINJP: ❑NEW WELL I❑RFPLACEMFNE WELL MONH—WELL I—„� Jj OTHER <br /> ❑INSTALLATION LJ WELL BYSTFM REPAIR ❑CROSS CONNECT AUPNR ❑VAPOR EXTRACTOR WELL ,V <br /> ❑N—❑WPM, I/,P. OE PTII PIMP 9ET_ :FT. PREF WATER LEVEL O <br /> fTYFf OF PVMP1 F�1 <br /> ❑OUT-OF-SERVICE WFLL ❑GEOPOYSICAL WELL r ❑ SOIL DONNO 6 <br /> ❑DEBTAVCTIDN, <br /> II-N-IiENp[p VEE �II--,YIf•E OF WELL CONSTRUCTION EPTCNiCATIONe fF A ••� <br /> IJ INDUSTRIAL IJ OPEN BOTTOM DIA,OF WFLL EXCAVATION DHA.OF CONDUCTOR CASINQ AIX D 1 <br /> F❑DOMEBTICNRIVATE ❑GRAVEL PA A_ <br /> TYPE OF CARINGIBTFELJPVC dA.OF WELL CASD�.t�y D <br /> I,J PUSLICDAUNICIPAL ❑mvEN DEPTH OF GROUT UAL SPECIFICATION <br /> }p❑IMRGATIONIAO ❑OTHER GROUT SEAL INSTALLED BYy DI1pVf BRAVO NAME ��+yam E <br /> �MONITORING y++ OIKIUT BEN,PUMPED: <br /> ll a CONCRETE PEDESTU BY—4;w- <br /> APPROX. <br /> F�r S . <br /> APPROX.DWnH "�1 ... LOC%IND CHESTER BORIRTOVE RPE s <br /> PROPOSED CONFTRVCTIONIDNLUNO METHOD:MUD ROTARY AIR ROTARY AUOER�_CABLE OTHER r <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPJCAMN AND THAT THEMW Wn-L BE DONE IN ACCORDANCE WITH BAN JOAOAAN COUNTY ORDINANCES,STATE LAWS.ANO MASS AND <br /> REGULATIONS OF THE SAN JOAWN COUNTY.NOME OWNER OR MCENSED AGENt'S SIGNATURE CERrIFIEB THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH <br /> THIS PERK IB ISSUED,I SHALL NOT EMP OV PERSONS SUBIECT TO WORKMAN'!COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIWNG ORSVB-COur CnND SMNATURE CEMIFMD <br /> THEF0110 NG: •I CERTIFY THAT M THE PERFORMANCE OF THE MW FOR WHICH THIS PERMIT IS 11RUED.I SHALL EMPLOY PERSONS SUBJECT TO WORIOAAN'S COMPENSATION LAW”OF <br /> CALIFORNIA THEA WANT MUST CRLL M HOURS IN <br /> ADVANCE FOR ML REOI.AREp HNEPESTIONS AT 1201111SSSL21,COMPLETE DRAWING AT LOWER APER VIpEtl, <br /> PLGT PWI IOrwY fe ScM•1 Sul• •tI�V . <br /> 7.NAME 1 OF BtREET1 OR S NEATEST TO OR ROLNDINO THE PROPERTY. I.LOCATION OF HOUSE SEWAGE DISPOSAL BYSTFM OR PIDPOSEO <br /> 2,OUTLINE OF THE PFIOPET .GIVING DIMENSIONS AVID NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J.DIMENSIONED OUTLINED AND LOCATION OF ALL FXISTINO AND PROPOSED B,LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALK". ON THE PLOPERTY OR ADJONINO PROPERTY, - <br /> Q uI M.s <br /> rr>v�1. <br /> .. ... <br /> rn+V <br /> mg 7— <br /> :.. <br /> 4 OEPARTINENT VSE ONLY <br /> .. AIPII-1-Ae ftHl OF },F'.V_-. n.....-S'71fv1��Arr <br /> f a—k p-K011 BY•� DH• P-P t,--am RY tir. F'-'••-••.• O•!• -.. <br /> DRnne Nrpxtlm BT O•[• , . <br /> p <br /> Z. <br /> AccpuxnxG axLr: AIDr FACE Y <br /> m COOPS FEE INFO AMOUNT REMITTED CNECOUMASH RECDVED BY DATE M�"TIONIVICE REQUEST NUMBER INVOKE 1 <br /> AAA ALJ n9-4szd5I2, <br /> M i <br /> i <br /> N <br />