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PLICATION FOR WELL/PUMP FERMI <br /> SAN OUIN COUNTY UBL C HEALTH EFOES <br /> -.NVIRONMENTAL HEALTH DIVISION ORIGINAL <br /> 304 EA:T WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Flow <br /> ICBmptetB In TTIpIkEtE) HE <br /> MIT TO CONSTRUCT AND1011 <br /> NSTALL T <br /> JAPPLICATION 15 14EM BY MADE TO THE SAN JOAQUIN COUNTY FOR A OAQUIN COUNTY DEVELOPMENT TNLE.CHAPTER 9-1115.3 AND THE STANDARDS OF BAN J AQU N COU((�� NNTTy�Y PUBLIC HEADESCRIBED.Title APPLICATION 16 MADE IIANCF WITH SAN <br /> LTH SERVICES,ENVIRONMENTAL HEALTTHDIMSION. <br /> � �/ / ��[e�r- CITU VYV V '✓I PARCEL SIZUAMS fA•7-y/-a9 <br /> JOB ADDRE59roR ARJI 10 /�/A1�0 /900 OW2/) S /'Z /� /,,,,� ylJ-00 <br /> $e./>< 9 5 De ecr.-rLs.Leo Cw.aldr.'R,dE,da.,, g� RIONE(_/�'� <br /> OWNEn'9 NAMEry� CAU MC-Ff/e1b `RP#fM/ ADDRESS <br /> ADDRESS <br /> UCI PHDNEI <br /> CONTRACTOR 4 (� c <br /> BU CONTRACTOR 7%FQ 1A1 �..] J ADDRESS / h4 f/L-,P2 UC/I yy�J�6� <br /> TYPE OF WELLIPIIMP: ❑ NEW WELL ❑ REPLACEMENT WELL <br /> ❑ MONITORING WELL# Ed OTHER-op <br /> G(NC(1 <br /> CTIC <br /> ❑ INSTALLATION 1] WELL SYSTEM REPAIR ❑ Chinon CONNECT REPAIR FIRST WATER VAPOR LEWELL# <br /> VEL _ O <br /> ❑New 11Reyell H.P. DEPTH OMP SET_FT. <br /> RYPE OF PUMP) ❑ 601E BORING B <br /> ✓„I / ❑ ow-0E-SERVICE WELL ❑ GEORIY61CAl WELL# <br /> ❑DESTRUCTION: T -[Z(pN a? P y A <br /> INTENDED CONSTRUCTION SPECIFICATIONS A' <br /> USE TYPE OF WELL O <br /> DIA.OF WELL EXCAVATION 1.51I,TL- DIA,OF CONDUCTOR CASINO ,,y <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM TYPE OF CA61NOI6TEEVPVC NIr DIA.OF WELL CASINO I✓eJ D <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACKI8DE <br /> ❑ <br /> OEM"OF GROUT SEAL r✓I I OPI�/ SPECIFICATION A <br /> ll <br /> L3 PUOUCIMUNICIPAL DmVEN p <br /> ❑ GROUT SEAL INSTALLED BY DKL I I'CK GOUT BRAD NAME CChL4 ""^e,�q[y,y E <br /> IRRIGATIONIAG ❑OTHER <br /> pF GROUT SEAL PUMPED: P(Ys ❑Ne CONCRETE PEDESTAL SY DRILLER: Yr [IN INN_�"I/ 6 <br /> Iq MONITORING // S <br /> LOCKING CHESTER BOX/STOVE RPF <br /> APPROX.or"" AUGER CABLE OTHER QP, <br /> PROPOSED CONBTBUCNONIORILUNG METHOD: MUD OTARV <br /> AIR OTARV <br /> 1 HE4EBV CERTIFY THAT I HAVE PREPARED THIS AIWJCATION AND THAT THE WORE WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,SNICE OF TATE THE AND RULES AND <br /> HAT IN THE pERFOIAMA <br /> REGULATIONS OF THE GAN <br /> JOA NON EMPLOYPEROHOME <br /> OWNER <br /> SUBJEi LICENSED <br /> WORAMBCOMNT'SIPEN6ATIDNGNATURE CUW8 OF CALIFORNIA.'ERTIFIES THE NCOMRACTOW6 HIRING OR SUB-CONTRACTING,SIGNATURE CERTIFE6 <br /> OF <br /> THIS PERMIT IB ISSUED, STALL <br /> THE FOLLOA NTM AP CERTIFY <br /> TTHAT IN TNE <br /> CALL 3 PERFORMANCE <br /> OFTHE ADVANCE FOR ALL LW to IE MM,,IN*MMNS AT ILM/I 4p. 23-A WHICH "IS PERMIT 19 ISSUED,I SMALL ECOMPLET DRAWING AT LOWER AREA PROVIDEDCOMD6AT10N LAWS <br /> CAL <br /> THIe�— <br /> e wee x <br /> RAT PLAN 0.,e SeJel 6e•Is I° <br /> t. LOCATION OF{LOUSE 6EWAOE DIBOBAI SYSTEM OR RtOO6ED <br /> J. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE DI8PDBA1 SYSTEMS. <br /> Z. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. <br /> Map <br /> DEPARTMENT USE ONLY <br /> APPIIc•Ilen Mcryte By <br /> D•u RP ,m•PeenPn By <br /> Due <br /> er <br /> �f1ANJGHl�U1NC I <br /> De 111.11 „Irn°eceon FNVIR <br /> cemme,e. CPT 175.E <br /> ACCOUNTING ONLY: <br /> AID/ FAC# <br /> PE CODER FEE INFO AMOUNT REMITTED CHECK#ICAGN RECEIVED BY DATE PEPMITISERVICE REQUEST NUMBER INVOICE <br /> 2 �o Zy <br /> Pub.Health SEN.-Enviro.173(1/97) <br />