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SAWDPPLICATION FOR WELL/PUMP PERM " <br /> AQUIN COUNTY PUBLIC HEALTH SEES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ( 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> /r (` (209) 468-3420 <br /> l NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1111 I ICampkta In TriprKstel \w`A�� <br /> APPLICATION IS AERP BY MADE TO THE BAN JOACUIN COUNTY FORA PERMIT TO CONSTRUCT ANDNn INSTALL THE WOR(DESCRIBED.THIS A ON 16 MADE IN COMPLIANCEWDII SAN <br /> JOAGUIN COUNTY DEWLOP. 605 <br /> M(EHT TITUF;C/HIAFTER 9- 115.3 AND THE STANDARDS OF SAN JOADUIN COUNTY PURU.C/HEALTH SERVICES.ENVIRONMENTAL HEALTH DMSION. <br /> JOB AOORE59/Oq APN/ V/ .5/ /V- _CITY) o�aj 7Y'h'�,l/J PA FLL SIZFIAPNE <br /> OWNER'S NAME f'V _ LYQ �Op �/I(f <br /> CSCONTRACTOR AOADDRESS F ' /�uoa LICp� PHOK?O <br /> BUB CONTRACTOR� ADDRESS / � IJckw�• .v—FV%U <br /> TYPE OF WELL/RIMP: ® NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I I❑q OTHER CGC O /J� ' <br /> ,f.1 ❑ INSTALLATION 1:1 WELL SYSTEM REPAIR ❑ CROSSCONNECTELL <br /> REPAIR ICI VAPOR EXTRACTION We J CC LS4l i J <br /> Nl/Y ❑New❑Pepdr H.P. DEPTH PLUMP SET—FT. FIRST WATER LEVEL 0 <br /> (TYPE OF PUMP) <br /> ❑ OUT-0E-SERVICE WELL ❑ GEOPHYSICAL MU-I ❑ 601E 00RNG B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPENBOTTOM DIA,OFWELL EXCAVATION "6- "1.2 " DIA.OF CONDUCTOR CASING N D <br /> ❑ DOMESTICAPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASIMMTEELNVC /YC Jh&( -/L) INA.OF WELL CASINO A G yy D <br /> ❑ PUBUC/MUNICIPAL 11DRIVEN DEPTH OF GROAT SEAL 6 SPECIFICATION 1 / -/� A <br /> INBWOATIONIAG /�❑OTHER GROUT SEAL INSTALLED BY�]NNb COVLHlLt�E"' GROUT DRANO NAME vl pr,T-�Pm TDhIIL. E <br /> Lq MON1TORNGkppraek' , OPAUT SEAL FUNIKO: ®Yr 11 No CONCRETE PEDESTAL BY DRLLER:❑Y- ®Ne S <br /> APPROX.DEPTHy 0/ LOCKING CHESTER BOX/STOVE RPE�VPS S <br /> PROPOSED CONSTRUCTIONIdBWNG METHOD: MUD ROTARY AIR POTARY AUGER_CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APCICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE VAT"SAN JOAQUIN COUNTY OPOINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WN10H <br /> THIS PERMIT IS ISBUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONFHACTOq'B HQONOOR W"ONTMCTING SIONATURE CEMT S <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL N MU IA IN ADVANCE FOR ALL REQUIRED(PHIMMMA AT 11OS144XI4NI23.. COMPLETE MU4WHG AT LOWER AREA PROVIDED. E. <br /> elarvd X _ �� TIII. e1/`e/"/'OT /-(Q�. D.la.rJ� <br /> 1 <br /> PLOT PLAN 10.pw to S.Y.1 S fil. 't- <br /> 1. NAMES OF STMEYS OR ROADS HEAUST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINES ANG LOCATION OF ALL EXISTING ANO PROPOSED 6. LOCATION OF WELLS WRInN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING R10PEHTY. <br /> Mop <br /> .$[lE _ 033 <br /> DEPARTMENT USE ONLY <br /> Applk.lb Aev.pled 01 OemxBy D.la p InlpmSen B1 <br /> —7 <br /> De.lndbn"PxOen B <br /> —D./1. <br /> C.-..: Z- <br /> ACCOUNTING ONLY: MOF FACS <br /> FE CODES FEE INFO AMOUNT MAIITTED CHECK/ICABN RECEIVED NY DATE 109YMTRERNCE REQUEST NUMBER INVOICE <br /> ZRo I Vii � Er 0 64ttlqS-� <br /> D/750 <br /> Pub.Health SEN.-Enviro.173(1/97) <br />