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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �m EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> ROR•AEFUITOAILE PERMIT EXPIRE! 1 YEAR FROM DATE ISSUED <br /> Ir.SEIplE1S In TF(rReS1E) <br /> AMICATON IB HERE BY MADE TD THE BAN JOAOLRN COUNTY FOR A PEFIMff TO CONSTRUCT AN01011 INSTALL 714E WORK DESCRBED.THIS APPLICATION IH MADE IN COMPLIANCE WRTII SAN <br /> JOAOUIN COUNTY GMLOFMENT TITLE,CHAPTER 9-111 S.3 AND THE STANDARDS OF SAN JOAOUIN COUNFY PUBLIC HEALTH SERIVICES,ENVIRONMENTAL HEALTH CAVISION, �ryI <br /> JOS ADDRESSIOM APNe. I -k CPTY PARCEL SII AFH ^1<4 <br /> OWNER'S NAME ADDRESS F4pNE,F 1627--84-70 <br /> CONTRACTOR + I <br /> Zjjc ADDIEBf �ty C*l�_- LIC# ,�l/ PHONE I <br /> out CONTRACTOR�.L_ € ( r�. ADD1+E+S. Ysft,{UC em <br /> TYPE OF WELUP MP-. )qSPEW WELL ❑ REPLACEMENT WELL MONITORING WELL# I ❑ OTHER <br /> ❑ INSTALLATM:N ❑ WELL SYSTEM REPAIR ❑ mas-CONNECT REPAIR CI VAPOR EXTRACTION WELL A <br /> ❑NeMr❑Repelr H.PSE <br /> . DEPTH PUMP T FT. FIRST WATER LEVEL__ <br /> (TYPE OF PUMPI <br /> ❑ OUT-0F-8ERVICE WELL ❑ OEOPHYSK:AL WELL# BOM SORINO g <br /> ❑4fSr10.1GTONf <br /> INTENDED Uaf TY O WM CONSTRUCTION OPECIRCATIONS A <br /> © INDUSTRIAL ❑OPEN SOrTOM DIA.OF WELL EXCAVATION_R ��s OLA.OF CONDUCTOR CASINO D <br /> ❑ DOMfsTIC1PR IVATE GRAVEL PACKISIZE L ..i TYPF OF CAS{NO//TEELIWC ry� _It. -'R.' DIA.OF WELL CASINO <br /> ❑ PUSLIClR�AUNRCRAL ❑ORVEN OPTH OF OROUT SEAL '�T- _ SPECIFICATION R <br /> ❑ IRISLEATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME tpa Ys• _ IF <br /> T � 7 n <br /> MONfTOWNG GROVTBEALR'11MPED:0Yr 13 Me COHCTETEPEDESTAL BYTIRLLERrA7g []No <br /> LJ Na <br /> APPROX.OEYTN LOCKING CHESTER BOXfSTOVE PIPE <br /> PROPOSED CORISTRUCTIONIOISLtM METHOD: MUD ROTARY AIR ROTARY AUGER V CAKE OTHER <br /> I HMNY CERTIFY THAT I IIAVE PREPANED THIS APPLICATION AND THAT THE WOR(WILL BE DONE ER ACCORDANCE NAT"SAN JOAOUOR COUNTY ORDINANCES,STATE LAW@,AND MULES AND <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING_'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFOFWRA, CONTRACTOR'S HIRING OR EU"OHTRACTWO RSONATURE CERTIFIES (� <br /> THE FOLLOWOM! •I CERTIFY THAT IN 771E PEPIFO E OF THE WORK FOR VAMH TMS rEF"TT IS I88UL"0,I SHALL EMPLOY PERSONS BUSJECT TO WORKMAW9 COMrMOATION LAWS OF <br /> CALIFOMAA." APFUCANT MUST CALL R 00VANCt FOR AM MEGMILQD INSF[L110NS AT 17.001111 4004%4!7. COMPLETE LMUNANO�AT LOWER AREA P OVIDm.p f <br /> % TIMe_�t C7<Q64.�'�S S8`f 2. DMS /�/L 7 /) <br /> PLOT MAN 0aw 1e Saelal @coil '10 <br /> 1. NAAIIES Of BTIM"S OM MADS WAVIEST TO IM BOUHDM THE FMOPEETTY- 4. LOCATION Of HOUSE BkINAGE DISPOSAL SYSTEM OR PFIDPOSEO <br /> R. OUTLINE OF THE PROPERTY,GIVING DIME 4 ME ANO FORTH TIEECTION. EXPAN&ON OF SEWAGE DISPOSAL SYSTEM!. <br /> 9- OPMENSIONED OUTUNF.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTTMIN RAINUS OF ONE HUNDRED FIFTY FT. <br /> STR11CTUIRES,INCLUDING COVERED AREAS SUCH AS PATIOS,D"VEWAYE,AND WALXS. ON THE PROPERTY OR AOJDPOM RDPERTY, <br /> i <br />' <br /> DEPARTMENT USE DINLr <br /> ApFBpetbn AeseAtsd BY_ ON• 7i Anr <br /> Graaf Impaction By ( , � Pti p I—poc"n BY Lista <br /> oompmtlen Ir"ro"k n BY Date <br /> Carrnw.fc� <br /> ACCOIWTMO ONLY- AD" FAC# <br /> PE CODE■ FEE INFO AMOUNT 14OWTTED CIIECKIICASH RECEIVED a DATE FEI"TISERVICE REQUEST N INWICE <br /> sol `d9•�o 2 o0 ob <br /> Pub Health Sm.-EnvirG. 173(1/97) <br />