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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVAS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 988,304 EAST WEBER AVENUE, STOCKTON, CA 95201988 <br /> (2091469-3420 <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TrlpRo@lel <br /> APPLICATION IB HERE BY MME TO THE RAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WRIT SAN <br /> JOAGUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSMA APNI i C I CRY 5'iZ c 1 —10 j PARCEL SIZVAPNJ 09-7-q/-0-4 <br /> OWNER'S NAMI�EGIJAI, 1-E py,y1LL'T-A�)ny AA-rsL/L6VP-+£-FR ILYf-N [yJ /2JgFLtryJl �47N AARES /6cOD I - r. <br /> LD NO <br /> NE I_ (d,I�4 <br /> 'A SH/ <br /> CONTRACTOR nn -- _ /''''!!_ --ADORE//BB--�J---.--__. �/fJ <br /> PVB CONTRACTOR ��I IZ��G T�/2(CLIA//7 QHN �Sllnp, ylccy(V/H�ADOKESe -/� �uc� A' "I*V]LHOJ V�IL•> pHONEJS%d-�/}•j�'V' <br /> 7 J 1Hy,FY <br /> TYPE OF WELIJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLA XJ'GTIIERG T FF�JJLo UN[I� <br /> ❑ NSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> RYPE OF PVMPI L1 N. Ro,* N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL G <br /> ❑ OUT-ORSERVICE WELL ❑ GEOPHYSICAL WELL J ❑ BOIL BORING B <br /> ❑DESTRUCTION: 712EN.0 IE F�k'R-A..,p (E"6,,J'T <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ OMESTIC/PTIVATE 11 GRAVEL PACK/SIZE TYPE OF CASDIOIBTEELIPVC DIA.OF WELL CASINO O <br /> ❑ PUBLIC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT REAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT BEAL PUMPED: Ely. ❑Ne CONCRETE PEDESTAL SY DRILLER:❑Ys ON. 5 <br /> APPROX.DEPTH (L/✓ TCtr LOCKING CHESTER BOXIBTOW PPE 5 <br /> PROPOSED CON/TRUCTION/DRSWNO METHOD: MUD ROTARY Ain ROTARY AUGER CABLE OTHER C PT <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPIICATON AND THAT THE WOR(WALL BE ONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY OMINANCES,STATE"We,AND RULES AND <br /> REGULATIONS OF THE BAN JOAOUN COUNTY. HOME OWNER OR LICENSED AGENT-8 SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PENPOnMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COW MCTOR'S HIRING OR SUBLO W MCTING SIONATUM CERTIFIES <br /> THE FOLLOWING: -I CERTIFY HAT N TIRE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IB@UED,1 MAU EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIONUWe OF <br /> CAUFORNIA.' THE APPLICA MUST CALL 2 IN ADVANCE FOR ALL REQUIRED INSPECTOR/AT I240P <br /> 1440,342S. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 61,P.4 x� ♦ i./ ? / 6P _ 6L-/t=_•�. L'At On. <br /> ROT M%RN.le SoOM Soft <br /> 1. NAME@ OF STREET$OR ROM@ NEAREST TO OR BOUNDBO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE dBPOBAL SYSTEM OR PROMMO <br /> Z. OUTLINE OF THE PROPERTY,OIVBO DIMENSIONS AND NORTH DIRECTOR. EXPMBION OF SEWAGE 01 PM SYSTEMB. <br /> S. DIMFNKONED OW ..B MIG LOCATION OF ALL EXHITMG AND PROPOSED S. LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STM/CTUMB.INCLUDING COVERED AMAB SUCH A�PVEWAYS.AND WALKS. ON THE PROPERTY OR ADJONIINO PROPERry. <br /> 1 LINCOLN SCHOOL <br /> MW <br /> r <br /> MW21 6\ Ca <br /> 0 <br /> 0 -�� $ OO MW9 ' o <br /> 2 MW12 $ t7 <br /> ier Norge s� o <br /> ;ng Village <br /> o� <br /> 15 10 <br /> 6® <br /> ® MW10 <br /> (9)CPT-100 1 <br /> $ 2 <br /> \ c <br /> CHMW-.-,, Mwll®5 a 3 P1�OPOSED CYTS <br /> \ <br /> H� Chevron \\ C W-� CHMW-3 <br /> \Gas Station 6 9 $ <br /> \ C yE <br /> Lo MW3 11 YPCTF� A <br /> DEPARTMENT USF ONLY <br /> APp1leHbn A.eepled BY i`Y Del._ I"/ , //) .�._At. <br /> G'oA lr P t PA BY 0M PUPP IMP.H.P$Y Sea _ <br /> Deo'ud P I.P.Iko BY Go. <br /> ceA,me.A.: tJP'Y=51'I� E55 AO FlIPM UNLD ►.l 1- LD 8N BILE <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK/ICASH RECEIVED BY DATE PDWLITI@ERVICE REQUEST NUMSDI INVOICE <br /> ti I2'IS 231 <br /> Pub.HeeOh Sew.-ENID.173(3/96) <br />