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APPLICATION FOR WELLJPUMP PERMIT <br /> S�AQUIN COUNTY PUBLIC HEALTH SES �/���`" `��_ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 4 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> (Complete In TripFieet6l <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THM APPLICATION IS MADE IN COMPLIANCE WTNI BAN <br /> JOAOUIN COUNTY DEVELOPMENT TITUE CNA"ER 9-1/1116.3/AND THE STANDARDS OF BAN"AOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. '7Cy <br /> JOBADDRESSIOR APNE c" 7VJ /)N(�p//.J ( PNL�L°.1'- CRY �70 C/-TdNELe1ZE/APNI_L�i��y�- // <br /> 9&4411,5 V,!) Getttii^� be Aldn.,.TLJ: (SD Ds) /900 Yawe11 V,ee /2 F/r- <br /> OWNER'SNAME /O T1rIdT Z ,�C ICPjr,�LADORESII�rh p.-.�Ui/�N, CK} 2,yr OE -/SoI7PARC PMNEFS�O � <br /> J <br /> CONTRACTOR - AODRE88 (JCI <br /> PHONE I <br /> PVB COWRACTORJ62PO04r-cc,„ AoonEse_Stnek LK:e cS7-S/ddb PPHONEea09-5'65-87, <br /> TYPEOF WELI/PUMP: Q9 NEW WELL ❑ FWUUCEMEW WELL ® MONITORING WELL 2 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT/REPAIR 11 VAPOR EXTRACTION WELL F <br /> ❑N.13 nee.], H.P. DEPTH PUMP SET,1//H "- FIRST WATER LEVEL O <br /> R YPE OF PUMPI TTT — <br /> ❑ OUT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL 2 ❑ BOIL BORING g <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION A i/ DIA.OF CONDUCTOR CASINO ty 0 <br /> ❑ DOMESTICR'mVATE ®GRAVEL PACK/SIZE # /O TYPE OF CASING/GTEEVPVC_JC9 VIA.OF WELL CASINO_.. ,7 T/ 0 <br /> ❑ PUBUCNAUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL T .3OY BPECIFICATION L <br /> ❑ IMIGAT10N/AG ❑OTHER GROUT SEAL INSTALLED BY .UY/��e/- GROUT BRAND NAME&110, IOeYH eA/G E <br /> ® MONITORING GROUT SEAL PUMPED: ®Y. [IN. CONCRETE PEDESTAL BY DRILLER:ICTI Yw [IN.Ne S <br /> APPROX.DLPTH Yq,9/ LOCKING CHESTER BOX/STOVE PIPE VP.$ a <br /> PROPOSED CONSTRVCTIONJDW LUNG METHOD: MUD ROTARY AIR ROTARY AUGEfl_ ( CAB—LE OTHER <br /> 1 HEREBY CERTIFY THAT I RAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE IAWe,ANO RULER AND <br /> REGULATIONS OF THE BAN JOAOUM COUNTY. HOME OVMER OR LICENSED AOEW'e SIGNATURE CERTIFIES THE FOLLOWING:'I CEITIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,1011ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENBATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 181SSVED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATON LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 2A 110 IN ADVANCE FOR ALL REQUIREDOINS/PECTOr,N�e AT 120111/e8JAA2A2. COMPLETE ORAWINQ AT LOWER AREA FRONDED. <br /> ela^°d X /'I QCO PIZ -n a P t— D.Ia <br /> PLOT MN ID,.le Sew.,Be.l. 'le <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DIBPOBAL BYBTEM On PROMSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING OIMENSION8 AND NORTH DIRECTION. EXPANSION OF SEWAGE MOMBAL SYSTEMS. <br /> O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF V/ELLB WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANC WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> M g P )qftQ c,� 11 4 .. <br /> DEPMTMENT USE ONLY <br /> APPll.allen Ae.,IM 11)—( D.1. [ `' A,.. <br /> ImPewen BT D.I. Pump In.o�nen By 0.111 <br /> Dwm.fl.n Lxnedlen BY D.I. <br /> Cemmax.: <br /> ACCOUNTING ONLY: AID/ FACE <br /> PE COD" FEE INFO AMOUNT REMITTED CHECKER:ASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 2 D •d <br /> Pub.Health Serv.-Enviro,173(1/97) <br />