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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN•OUIN COUNTY PUBLIC HEALTH SEIOES <br /> ENVIRONMENTAL HEALTH DIVISION I Q <br /> ff <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 952020R G NA <br /> L <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplob In TrlpReole) ` /7 <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION i6 MADE IN COMPLIANCE wlTN SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE�CHAPTER 0-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ,.L <br /> / // /� L / / yah,Al. B.NaZ E.. <br /> JOBADDRESSORAPPS c37t0 FIA/CIOIN ( Pli 1— CR 'sTO C/C 7'." PARCELSIZF/APHf7kaF_iC F✓,. Roe,.Sa*A16vy 'Dry C�IeaN/ be Ald y.a TEs (Sa Ds) /90o ;%We.11 ,L_ee /Z F//- —� <br /> OWNER'S NAME CIO h IdTa <'FI JTLU e f ^n?jAMRES9 Fr. //&, CA 9ybo8 -/8 n77 NroNEIS/O-(oS,7-S/SDp <br /> COMPACTOR ADDRESS LLCS PHONE I <br /> O 2365 W:9axcm ��. <br /> SUB COMMCTOR. pe'7` u(X -. ADDREBe .5tec.F)�++ CA 9S�oS ucrCS7-S/,?a6YP11DNe E,709-565-87 <br /> TYPEOFMI-I-PUMP: ® NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL S ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRABB-CONNECT <br /> /REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> NJ/a ❑N.11 Rep.l, H.P. DEPTH PUMP SET ,1NH FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) TT� <br /> 0OM-0E-SERVICE WELL 0OEORIY6ICAL WELL ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION )1 r,� DIA.OF CONDUCTOR CASINO AI/A D <br /> ❑ DOMESTICMRIVATE ®GRAVEL PACKIMZE # I(a TYPE OF CAGINGRREEL T VC JC Y //0 Plat DIA.OF WELL CASINO D <br /> ❑ PUBUCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAI SPECMCATION .L R <br /> ❑ IRNGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME Vea.,/. CEYH G'NL E <br /> ® MONITORING GROUT SEAL PUMPED:®Yr ❑NP CONCRETE PEDESTAL BY DRILLER:®Yr [IN. 5 <br /> n / <br /> APPROX.DEPTH Y� LOCKING CHESTER BO%/STOVE PIPE , e� S <br /> PROPOSED CONSTRVCTIONIDNWNG METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF TIRE WOR(FOR WT11CH <br /> THIS PERMIT IS ISSUED,I SHAM NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONTMCTINO SIGNATURE CEMMES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUBMID(IINSPECTIONS AT IZOEI 4"3 23. COMPLETE DRAWING AT LOWER AREA PPOWDEO. <br /> BlonedX /c �� \� 1 TIll.a1i le PPO Pt-7z Ala 'sz AP.y-- D.te C / <br /> c/ \ <br /> POT PAN II).µtP SP.lel Bc.l. -to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On P MIRPD <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2. 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 WAU(S. ON THE FROMMY OR ADJOINING PROPERTY. <br /> M gp lgfkc,� cc(.. <br /> DEPARTMENT USE ONLY 3lop �/(�///��`/�'y/ <br /> Applicetbn Accepted By Do. ✓ / .R N.._4V �• / <br /> O,eN Inepxllen By D.le Rnlp In.PePtlpn By V.I. 'T <br /> Oe.ln.abn ImnecGen By D.R. <br /> ACCOUNTIM ONLY: AID/ FACE <br /> PE COD" FEEINFO I AMOUNTREMITTED CLIECKNMASH RECEIVED BY DATE PUMnT/SERVICE REQUEST NUMBER INVOICE <br /> (�J � •2U O <br /> Pub.Health Sam-Enviro.173(1/97) <br />