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APPLICATION FOR WELLIPUMP PERMIT • CJ'T <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES A47- /SSU E/3 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 3K 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICamplete In Triptkidel <br /> APPLICATION 19 HEM BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE MW DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WRIT SAN <br /> JOADUIN COUNTY DEVEL)OOPM1E1NTT INTLE,GCHAPTERS-1 116.3 AND THE STANDAMD9 OF SAN JOAQUIN COUNTY WBLIC1HEEALTH SERVICES,ENV IONMENTAL HEALTH DIVISION. I' <br /> JOB ADOMSSIOR`A,P1LNLf LLL `Q"1`V'(�FTVQIEV.Q, �LpI n�CGIfL�EI\72�) CT(I��/� 1�S4�MD• (� ` PARCEEL BIZE/APNf_ -/ — <br /> OWNER'S NAMEy\\`�n�\1 CIV 1K^IIw. 0 4A. C.10 ADDRESS � IW' 11'�Vl'.11 J1;,1�TM%% [_MwYJ11K���ll PHONE/(r(V)65 5-co <br /> F9PflMEFM <br /> /� •'0taasM�a,5; Pryju!PP�onT.yttl J�/,��.ti.Fri�W,•Re-Ln <br /> SUBCOMMCTOR <br /> ADDRESS 95 <br /> 01VIPtiAtl;�ICf 41(�-0Y(1 `0PHONE)(5lo)3i3-53x7 <br /> TYPEOFMUJPJMP: ❑ NEW WELL i ❑ MPLACEMENT WELL ❑ MONrrGRIM muN ❑ OTHER Cif l�(4yp(��1',aKh <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION NEWELL f J <br /> ❑New❑Nevm' N.P. DEPTH RUMP SET—FT. FIRet WATER LEVEL O <br /> (TYPE OF RUMP) <br /> ❑ -0Rfl1 <br /> OUT6ERMCE WELL ❑ OEOY61CAL WELL f ❑ SOIL BORING B <br /> '9 <br /> IL}DESTRUCTION: `r�0"Y��� � `� CX.-k GI—V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> 11 INDUSTRIAL ❑OPENBOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTICPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINOISTEEL/PVC DIA.OF WEU_CASINO D <br /> ❑ PUSUC/MUNICIPAL ❑DmVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRNOATION/AG ❑OTHER GROUT SEAL INSTALLED BY SPOUT BRAND NAME E <br /> ❑ MONITONNO (�- (( GROUT SEAL PUMPED: ❑Yw ❑Na CONCRETE PEDESTAL BY DRILLER:❑Vw ❑Ne S <br /> APPROX.DEPTH ICU r LOCKING CHESTER BOX/STOVE RPE /' 1� S <br /> PROPOSED CONSTRLUCTIONIdtlLLINO MET"OO: MUD MITAnV AIR ROTARY AUGER CABLE OTHER CPT <br /> 1 HERESY CERTIFY THAT I HAVE PREPAMO THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WIT"BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE BAN JOAOLN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT W THE PEMORMAME OF THE WORK FOR WHICH <br /> "416 PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO W ORIVAAN'P COMPENSATION LAWS OF CALIFORNIA.' COWMCTOR'S HINNO OR SUS<OMMCTINO 61ONATUM CERTIRES <br /> E FOLLOVANG: -1 CERTIFY THAT M THE PEMORMANCE OF THE WORK FOR LMIICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WONKMAN'a COMPENSATION UWB OF <br /> -ALIFORMA.' T N MUST CA ADVANCE ADVANCE FOR ALL REOUREO INPPECU0N4 AT 12aa14"41M22. COMPLETE GRAMM AT LOWER AREA PROVIDED. p <br /> 61v,wdx Cr✓ .. L�5 �151P/17 fP� C"Kti��IM...�;I k�IR. Cv� �ti^��c�5YAdZC 0.4e (I <br /> PLOT IRAN IDrew m Sc V.1 6 A. I 4e 150 7 <br /> 1. NAMES Of STREETS OR WADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE NOMM.SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEMB. <br /> 2. WMENI RINED OU`HJW.S ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTFRN RADIUS Of ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPKE OR AD I ING <br /> e <br /> ` W100 s® MW10 <br /> ® CPT-100 <br /> GQMW LOl <br /> 2 <br /> CHMW-5 m W11 ®5 3 <br /> ® \ C -4 10 4 <br /> ® \ H <br /> \ CH W- <br /> P��� a Chevron <br /> CPr �S `Gas Station \\ 8 . 9 CHMW-3 <br /> C v1v� <br /> 12 MW3 11 1 4PCI P <br /> Immommm' i-Amm <br /> CHMW-7 CHMW-6 <br /> 13 O 150 FEET <br /> Station <br /> 1 <br /> I <br /> I <br />