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6 APPLICATION FOR WELL/PUMP PERV-- A <br /> SA. jOAQUIN COUNTY PUBLIC HEALTH SL /ICES Y �/ <br /> ENVIRONMENTAL HEALTH DIVISION V (19I <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> C� (209)468-3420 1 I� B�� <br /> / <br /> 1tGu NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate► l� <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TI APPLICATION 18 MADE IN COMPLIA E vmN SAN <br /> \\\JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HHEALT/�H SERVICE.ENVIRONMENTAL HEALTH DIVISION. <br /> �(OB ADORESS�OR APNIP 1 O / I N O • M {A�I� c^�• CITY AN CG/�.,1 PARCEL SIZEJAPNI <br /> OWNER-SHAME sopp`L L 0%t- �yy V(— S ��� ADDRESS '''LBO G O �7 1"1 I NEZ GA PHONE I 1l)�35-5y.0�.7.� <br /> CONTRACTOR C 'JQ'(/A.,' EN ryI(JRoNM6/N/,.1�- ADlN1E661'p�G'1 -✓ SI• LICI_ NEi- `J TLu'//I <br /> SUBCONTRACTOR �,-/M llT'-1(t'-V t I•�/ ADDREtiB 1%IU �/�r�F. �D.I 4 G{F ZUC/ PHONE I x910 �Ii-5� <br /> TYPE OF WELUPUMP: L'7 NEW WELLS(�)❑REPLACEMENT WELL ❑MONITORING WELL/r IW`I wW:3❑OTHEll <br /> I ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CnOSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL/ J <br /> I ❑Nen❑Repdr N.P. DEPTH RUMP SET FT. FIRST WATER LEVEL O <br /> A (TVP:OF PVMPI <br /> ❑OUT-OF-SERVICE WELL Cl GEOPHYSICAL WELL/ ❑ SOIL BORING S <br /> + ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION aPECIFICATIONII A <br /> QQ 1i <br /> 11 INDUSTRIAL ❑�..O//PEN BOTTOM DIA.OF WELL EXCAVATION /J DIA.OF CONDUCTOR CASINO � D <br /> ❑DOMESTIC/PRVATE IYJORAVEL PACKJ6IZE TYPE OF CASINO/STEEVPVC T VG DIA.OF WELL CASINO �i1{� O <br /> ❑PUBLICMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SP`ECIFlCATIONIA T U� R <br /> ❑l ttRRIGATtoN/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT"RAND NAME E <br /> L!S MONITORING GROUT SEAL PUMPED:❑Y•• [IN. CONCRETE PEDESTAL BY DPSl1ER,[1Y- ❑Ne 5 <br /> ! <br /> APMOX.DEPTH -/O LOCKING CHESTER SO STO RPE 5 <br /> PROPOSED CO"�TRt/CTiON/DISLUNO METHOD:MUD ROTARY AIR ROTARY A R_�CABLE OTHER <br /> V7 GO�lS�2Ut rON / ESD <br /> I HEREBY CERTIFY THAT I RAVE PREPAREO THIS APPLICATION AND THAT THE WORK WILL E DONE 1 ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'$61GNATU ERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT <br /> 191S 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOq 'e COMPENSA N LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWI HA I E PERFORMANCE OF THE F R ICN THI RMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIVAAN'e COMPENSATION LAWS OF <br /> CALIFORM . A AN T 24 1 a IN ADVANC F LL EO ED ePECTTIONNd AT 12MI Lae Se22.COMPLETE DRAWING AT LOWER AREA <br /> 1P`ROOVIDDE/D. <br /> TI <br /> KOT (Dr 0.I Sed• P to <br /> 1.HA TMETS OR ROADS N REST TO BOUNDING T i'E 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,OIINO DIMEN6ION8 AND RT DI CT N. EXPANSION OF SEWAGE DISPOSAL SV97EM9. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL AND <br /> O A D SED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PA rob O AVS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> re <br /> mcg` f <br /> 74e WK, <br /> ":IUVX4�2AD(13J <br /> DEPARTMENT USE ONLY ��sT <br /> Appil-0—A-Wt•A By V Y D•t.- —A- <br /> 8, <br /> r.. <br /> OroAA Imp•.tlpn Br D•t• Pump In•p 11—11 DU• <br /> D••aumlpn I-p-tlen By Dn. <br /> comm>,u: <br /> ACCO UNTINO ONLY: AID/ FACT <br /> PE CODES FEE INFO AMOUNT R TTEO CHECKFICASH RECEIVED OF DATE ►RMITISIERVICE RIOUEST NUMB@' INVOICE <br /> Q <br /> 7slrI <br /> Pub.Health Serv.-Enviro.173(1/97) <br />