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T APPLICATION FOR WELL/PUMP PERMIT <br /> SANAbOUIN COUNTY PUBLIC HEALTH SER&S / L <br /> NWENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 G <br /> (209) 468-3420 �V <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tril l'wEu) <br /> APPLICATION IS ASPS BY MADE TO THE SAN JOAQUIN COUNTY FOR PERMIT TO CONSTRUCT ANOMn INSTALL THE WOW DESCRIBED.TIIIS APPLICATION IS MADE IN COMPLIANCE WDTII BAN <br /> JOAQUIN COUNTY DEVELOPMENT TNLLF CHAPTER 811116.3 A/ND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> ` / p <br /> JOB ADORESSMRAPN/ " l0 1;,(,oW ( PRICK T— CITY S'/�OC/c7tr, I PARCEL SIZE/APNI <br /> Se#UNy 'Dry GeL ,! De ActaLs ODDs) /900 pbe all 7 -ee <br /> OWNUTSNAMEC/OTS lclT 3 aC/am) 4U' e <br /> CF? 9'/&09 -/847 PHONER S/O'(Sd-SZSOO <br /> CONTRACTOR ADDRESS LIC/ PHONE/ <br /> a36r w;GftJ0.YY1 �,-. <br /> SUN CONTRACTOR u,. ADDRESS S/-ee��++J C'A 9S,7oS UCICS7-S/dd68PHONE Ie109-'/68-87, <br /> TYPE OF WELUPUMP: ® NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT/REPAIR [I VAPOR EXTRACTION WELL F J <br /> N�ja ❑New❑R .I, N.P. DEPTH NMP BE N//'1 -- FIRST WATER LEVEL 0 <br /> (TYPE OF MMPI T <br /> ❑ OUT-0F6ERVICE WELL ❑ OEOPLIV6ICAL WELLI ❑ 601E BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION p ✓ DIA.OF CONDUCTOR CASINO /OV/�'J O <br /> 11DOMESTICImVVATE ®GRAVEL PACK/BIZE # //O TYPEOFCASINO/STEEVaPVC C'g 4/0 /�r,�/C DIA.OF WELL CASINO N y/ O <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GREW SEAL -3O� SPECIFICATION N <br /> ❑ MIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY �Y/IIe BMW BRAND NAME&Ca1 QC'I"EN6L E <br /> ® MONITORING GROW SEAL PUMPED: ®Yr ❑NS CONCRETEPEDESTALBYDRILLER®Yr CIN. 5 <br /> n <br /> APPROX.DEPTH Y� LOCKING CHESTER BOXISTOVE PIPE *S S <br /> PROPOSED CONSTRUCTIONIDNLUNO METHOD: MUD NOTARY AIR ROTARY AUGER X CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,LTATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PENORMANCE of THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUER,I e14ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CA/LL1 3/1MTURS IN ADVANCE FOR ALL REQUIREDINS/PECTIONj$AT IJO$I 4S/-SJPL <br /> St]. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Blamd X !il. �,/.-- "{T� /// TIP.—3,r� Fro <br /> P L'z.}ro 1 Manz a e Y^ D.te <br /> MOT PLAN IW.w to IMwal 9`016 'le> ""'777--- <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PMro6ED <br /> 3. OUTLINE OF THE PROPERTY,OIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEMS. <br /> 3. 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 WALI(S. ON THE PROPERTY OR ADJOINING PFgPERTY. <br /> Map )qftQ c,� rn <br /> � - <br /> DEPARTMENT USE ONLY <br /> Applle.tlen Acaapled BY Dw F Ar.. <br /> OroU Inepmtlen By D.te Pump Imp«tlen By Dae <br /> b..bwUen ImPmtlan By Ort. <br /> Demmer,,.• Fi9�s� . f 47 v — <br /> � i v <br /> ACCOUNTING ONLY: AIDS FACF <br /> PE CODES FEE INFO AMOUNT REMITTEO CHECIUMASH RECEIVED BY DATE PEMSTISERVICE REQUEST NUMBER INVOICE <br /> 24© I I �.�" 333 t S ��•� �- O! Pg <br /> Pub.Health SEN.-Enviro.173(1/97) <br />