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APPLICATION FOR WELUPUMP PERMIT <br /> L SAIWAOUIN COUNTY PUBLIC HEALTH SEES <br /> ENVIRONMENTAL HEALTH DIVISION'qv <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 "L <br /> ( 468-3420 <br /> 110111-REFUN9pBLE PERMIT EXPIRES 1 YEAR FROM DATE 199UE0 O v <br /> I"BoPIBts In TrfppKu2) <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR PERMIT TO CONSTRUCT ANDroR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCEWTN SAN <br /> JOAQUIN COUNTY DEVELOPMENT TRUE;CHAPTER 9.1116,9 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNI e I "T , C7E <br /> h'0what--�IJC� t1MA�If' PARCEL61ZPHONE (`�97-�/- 73 <br /> OWNER'S NAME / D 1'eL�R u / /90o Powe.))5+.,/z <br /> '� F L P-MN A' PHONE <br /> rn 9vG nlg� <br /> PHONE <br /> CONTRACTOR <br /> ADDRESS <br /> ,�pOgtseUCE <br /> PHONE <br /> OUR CONTMCTOR2Mry /,4 ,n "'e"' 4 U gra <br /> rC. M' lob 669 PHONE 9i6 P,SS-Y0/c <br /> TYPE OF WELL/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑ <br /> RVPE OF PIMP Nvn 13Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> O <br /> ❑ OUT-OF-SERVICE WELL 13GEOPHYSICAL WELL I SOIL BORING O^ B <br /> ❑OE6TRUCTION- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO AJ/r9- D <br /> ❑ DOMESTICIPNIVATE ❑GRAVEL PACKAHZE TYPE OF CASING/STEELfl C VIA.OF WELL CASINO / O <br /> ❑ PUBUCRJUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL .4../,{ 7*ofe/�yvo SPECIFICATION (I e <br /> ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY i+'/<F �/j��P/ GROUT BRAND NAM F ry)�A.J' E <br /> 11 MONITORING D FROM SEAL PUMPED: IN you []No CONCRETE PEDESTAL By DRILLER❑Vs ON.Nay S <br /> APPROX.DEPTH SU }- LOCKING CHESTER BOX/STOVE PPE <br /> / 5 <br /> PROPOSED CONSTiHUCTONRXNWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER r-A__ 14(4, <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE UW6,ANO RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERfiFY THAT IN THE PERFOnMANCE E THE NAP(FOR WRAC. <br /> TNI6 PERMIT IB ISSUED, SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENMTION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING; .I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIOM LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUTT CALL 24 HOUR/IN ADVANCE FOR ALL REQUIMO HIISFEC1I0 <br /> 1olAT UMN 40111 /X22, COMPLETE DFAWNO AT LOWER AREA P D"OtD. q/Y) <br /> 61--` X ! "Ch—.�\ �� 1 TRI. S/ Te rMlPC/e /telO d O.t� D.I. <br /> PLOT PLAN(0'.m Soal.1 6c.le 'to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE POPERTY. /. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PTgIg6ED <br /> 2. OUTLINE OF THE POPERry,GIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIGPOGAL SYSTEMS. <br /> G. DIMENSIONED OURINEe AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTIHIN RADIUS OF ONE HUNDMO FIFTY FT. <br /> STRVCTURES,INCLUDING COVEREDAREASSUCH AS PATOe,DRIVEWAYS,AND WAU(S. ON THE PROPERTY OR ADJOINING POPEnry, <br /> m 'qp <br /> DEPARTMENT USE ONLY 2 <br /> APVllcellen Accepted By �V Mu W <br /> Grain lMPecllen BY Dete Ptenp InepeNlen BY D.le <br /> Ueancllen lrnppC6an By <br /> 5 0.1. <br /> Cemmatic � 1 �� <br /> ACCOUNTINGONLY: AID/ FAC/ <br /> PE CODES FEE INFO AMOUNT RFI.IITTED CHECKIMASH RECEIVED BY BATE PEMGTISFRVICE REQUEST NUMBER INVOICE <br /> M. � - /Sag <br /> Pub.Health Sew.-Enviro.173(1/97) <br />