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JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. SOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 482-3420 <br /> AQWREFUNDABLE PERMrT <br /> I <br /> APLICATION 16 HERE BY MADE TO THE SAW JOAOU{N COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTILL THE WORK DESCFCBED.THM APPLICATION 16 MADE IN COMPLIANCE WITH 6A/ <br /> JOAQUIN COUNTY DEVELOPMENT TTTTE,CHAPTER H-1 1 11 5.3 AND THE 6TANOAR`DB OF SAN JOAOVIN COUNTY PVBLIC HEAL <br /> TH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> RE <br /> JOB ADO6810R APNOL// ��I /LJI 1.j �/L' /�'��'ll�l -�% J L cr Ll5i CITY 1`•l 1, Ill PARCEL SLMA➢N, <br /> OWNER•B NAME /U/— L AJl'C{:iC/J ADDRESS /TtN�4-N PHONE♦ <br /> CONTRACTOR` J / c ,.00RtE66�.'r L� h),St-z !Al UCJ PHONE A/• E -Z. 12._ <br /> SUMCONTRACTOR_ {r'//�L I�j L" J` _ ADOItEss {� clk--y, nk' �'�-�, ucs PHONEr /., 2l <br /> r 4 <br /> TYPE OF WEU,TUMV• ❑ NEW WELL ❑ REPLACEMENT WELL Ll MONROForq VvELL i OTHER <br /> Cl INSTALLATION ❑ WELL SYSTEM REPAIR ❑ C14ORS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL J ✓ <br /> ❑N—❑RMV.h H P. OEPTH PUMP SET FT. RRST WATER LEVEL O <br /> (TYPE OF PVMP1 Fes. 1 n <br /> ❑ OVT�OF-SERVICE WELL ❑ GEOPHYSICAL WELL r YY 801E 60RtNo J/K L'Z T /'mss SQL//- ' : B <br /> ❑DE STRVCTION: <br /> INTENDED UvE TYPE OF WELL CONSTRUCTION ZVWX4CATIONZ A <br /> ❑ WOUBTFOAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO D <br /> ❑ DOt.1ESTICIVAT ❑GRAVEL PACKISrZE TYPE OF CASINGIS'TM-11C DIA.OF WELL CASING D <br /> ❑ F'VBUCIMUNFCIPAL F❑-�OPoV1:N DEPTH OF GROVT SEAL SPECIPICATION F <br /> ❑ IWAGAT10N/AG ❑OTRTER OFIOVT VEAL INSTALLED by OROLrr BAANO NAME E <br /> ❑ MONROFUNO < OROVT SFAL PUMPED: ❑Y.. [IN. CONCRETE PEDESTAL BY DRILLER❑Yr ON. s <br /> APV"OX.Oa7TH ? ,,.J LOCKING CHESTER BOXISTOVE PIPE s <br /> PROPOSED CON*TRUCTIONIDIItWNG METHOD: MUD ROTARY AIR ROTARY AUOEA CABLE OTHERJ!7- <br /> 1 HEREBY CEFtTWV THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN kCCOFtOANCE WITH SAN JOAG(AN COVNTY OFIDINANCE6,STATE LAWS,AND RULES ANL <br /> REOVIATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERT114E8 THE FOLLOWING: 'I CERTIFY THAT IN THE PERIFOPaAANCE OF THE WORK FOR W141C1 <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS BUEJECT TO WORIaAAN'S COMPIENSAYTON LAWS OF CAUFO1VAA-' CONTRACTOR'S MPoNO OR SUB-CONTRACTING SIGNATURE CEFiTIF1Et <br /> T1IE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK POR WHICH THIS PERMrT IS ISSUED,I SHAD.EMPLOY PEF4ONY BVDJECT TO WORKMAN'S COMPVYOATION LAWS Of <br /> CALIFORMAi' T A►.1►CANT MUST CALL 24 HOUR*M ADVANCE FOR ALL R10t40"INOPTCTIOIt*AT(2061 400,V-422. COMPLETE DRAWTNO AT LOWER AREA PROVIDED. <br /> S1v...d [,1;GG-' (/y.�,{!�•�1'►Z Z't/ Thl. V L-Kl WH! I /k v .�/v16'l I�(; <br /> •V MDT R'LJtN (DvW t.9—J.)So.+. 'to <br /> t. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROP(RTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P OMSEO <br /> 1. OUTLINE OF THE PffOPFRTY,OMNO dMENee0N8 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 7. DIMENPJONED OVTLwF.w AND LOCATION OF ALL MSTINO ANO PFIOPOS£D S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fr. <br /> STRVCfVRES,INCLUDMO COVETED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOIMNO PTIOPEATY_ <br /> T7 . . ....... <br /> MAP ON BACK <br /> ............ ............... <br /> ........... ............ <br /> .. ...................... 1 <br /> OEPARTMEl1T USE ONLY <br /> AOPitwUo..A.P.pled By / <br /> D.0 S l � Au.. <br /> a.A w»e.etle..By Dag PW rnp hrP. 6—By D.t. <br /> De.Iructbn Mwv.otbn By D.t. <br /> ACCOVNTINO ONLY: AID/ FAC# <br /> K CODES FEE INFO AMOUNT P"ArTTED CME /CASH RECEiVfO[Y DATE PIWATIAL"CE RFOVFAT NLWARUR INVOICE <br /> )7"L 9IL) <br /> I%�lz l <br />