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PPLICATION FOR WELLIPUMP PERMIT <br /> SAN_-jAQUIN COUNTY PUBLIC HEALTH SEF. .;ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CempMtl In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WrTH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TR ,CHAPTER 9-111 Ci.3 A1ND THE <br /> ,�STANDARDS OF 6 N JOAOUIH COUGNFY.{/y�18LIC HEAL1TH�SEER ACES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNI ' {�10 )L �5 1L{tom'l 15 <br /> 4/�� GRV �+'�/�(, I+(—}gyp ✓I PARCEL SIZEIAPN/ <br /> OWNER'S NAME L 1✓!- V ADDRESS }1 z (PHONE Or �r9y1';) y' -T <br /> CONTRACTOR L 7 r �L l� j ADDRESS V r x{1. r�]V I JL(��I UC/ Z ;C+ PHONE' 1��LD <br /> SUBCONTRACTOR I ADDRESS 930 !lIW/[i *UC/ -435-l6V PHONE Ifv 3570 <br /> TYPE OF WELLIPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL/ ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL I J <br /> ❑N—❑RpWr H.P. DEPTH PUMP SET FT FIRST WATER LEVEL O <br /> rr OF FUTPi <br /> vn' ❑OUT-OF-S°E�R�VI�C'E WE 11 <br /> / ❑OOEORiVI61CAl WELLI ❑ 601E/BOe�Po,NGg 8 <br /> ESTRVCTION:� 1 — Z(( •rvV VL IT V`! IAIO 4`� A x (lV�T✓�17V 4/`+1. <br /> /INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS- A <br /> ❑INDUSTRIAL (3OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑DOMESTIC/RSVATE 11GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC V L DIA.OF WELL CASINO ZI O <br /> 13PUBLIC/MUNICIPAL 11DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A <br /> ❑IRRIGATIUNIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONITORING t 1 1 It (' GROUT SEAL PUMPED:❑Yu ❑No CONCRETE PEDESTAL BY DRILLER:❑Y_ CIN. 5 <br /> APPROX.DER" �( 1/ 7 LOCKING CHESTER BOX/GTOVE PIPE 5 <br /> PROMSED CONSTRUCTIONMAILUNO METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> IHE9EBY CERTIFY THAT I RAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES MD <br /> REGULATIONS OF THE GAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE W01K FOR WHICH <br /> THIS=IT IS 65UED,1 SHALL NOT.MPLO RSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLO '1 CERNFV HAT TII PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'!COMPENSATION LAWS OF <br /> CAUFORN11 RIE A ANT CA }4 HOAR$IN ADVANCE FOR ALL REOURED©INSMTION,SI AT(20411444-1422.COMPLETE DRAWINO AT LOWER AREA PROVIDED. <br /> Stv—d X TItI. 1 1,\0 c) <br /> PLOT PLAN ID—to SeW.)Sod. to <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. i.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLME OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, 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 PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 1 :.....:. ... .....�. :.....:. ....... <br /> DEPARTMENT USE ONLY <br /> APFr.Ilon Aea.Pt.d BY <br /> Groot Irwpstlon Bf IW i4A —D.b P.ne I"P,r.t..,.B, DH. <br /> D,wlrtrlbn IrrP.etien BY 0.1. <br /> CemmrN� <br /> ACCOUNTING ONLY: Me FAC/ <br /> PE CODES FEE 1-0 AMOUNT REMITTED CHECKI/CASH RECEIVED by DATE ►SNIT/SERVICE REQUEST NUMBER INVOICE <br /> a a— 6- 1 ,3 --) <br /> Pub.Health Serv.-Enviro.173(1/97) <br />