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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDARLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> IRC <br /> APPLICATION 19 HERE By MADE TO THE SAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMRINSTALL THE WOR(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER/9-1116.3 AND THE SrANOARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SEIWICEe,ENVIRONMENTAL HEALTH DMSION. �(J <br /> JORAMMS9,ORAPHS Wirlay) Qr1 / w4� C)()sL+ r& <br /> `' 1 S hrA�.y�t- CITY l-Q 'llff,0 PARCEL SIZE/APHI I,��n r <br /> OWNER'S NAMEJy�yl(1_ am(�Qn ..rnmf: Incaacla i �,�1 <br /> 3 ADI3RE88 nYY1Ln7) 11nMnn PHONEI1=1 UR- S7 <br /> CONTRACTOR <br /> SVS CONTRACTOR AOp10BSL.�nl�1\ ---.� 11CI tib. �� ry /nz_�. pl__n7 <br /> — yrF PHONE 11-yX11(QGL.I <br /> ADORE98 IEEmmn4 IleaUCFC.e-. ; l— <br /> i�$�ly�lpl ONE Z S I' <br /> TYPE OF WEURUMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONTTORINO WELL I , <br /> ❑ <br /> INSTALLATION ❑ WELL SYSTEM REPAIR ❑ OTHER <br /> ❑ CROSS-0ONNECT REPAIR ❑ VAPOR EXTMCMN N. WELL I_ <br /> ❑N ❑RelrNr N.P. ✓ <br /> (TYPE OF PUMPI DEPTH PHMP SET FT, FIRST WATER LEVEL O <br /> 11 DESTRUCTION: SERVICE❑ OOT-0F SERE WELL 11BO <br /> GEOPHYSICAL WELL I BOIL RING I`/ B <br /> INTENDED ULE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL 1-1 OPEN BOTTOMA <br /> GIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> 11M <br /> DOEBTICRIIIVATE ❑GRAVEL PACK/SIZE O <br /> TVR OF CASINO/ST L/PVC <br /> IJRIRLN:IMUNICro ❑ VE <br /> AL ORN p <br /> DEPTH OF GROUT SEAL <br /> DIA.OF WELL CASINO <br /> L❑ SPECIFICATION <br /> MONNOPoNG TION11 OTHER TIMM SEAL INSTALLED BY R <br /> ❑ ONITOIgIR BRAND NAME E <br /> APIAOX.DEPTH <br /> GROUT SEAL PVMRO: ❑yr ❑Ne CONCRETEPEDESTALRVORIMMo Y- [IN. S <br /> LOCKING CHESTER BOX/STOVE RR <br /> IgOPoSFD CONSTTTUCTLONIpNWNO MELWO: MUD ROTARY S <br /> AIR ROTAm AMER CABLE <br /> OTHER <br /> Fill: ONS FY THAT I "A IN CM THIS Ap{TA:ATION AND TNAT THE NRR(WILL eE DONE M ACCORDANCE WIT1/SAN JOAOVIN COUNTY ORD INANCES,STATE UWe,AND RULES AND <br /> THIS KTIONS OF THE SAN JOAOVM COVNTY. NOM E OWNER OR LICENSED AGENT'S SIGNATURE CERTNIEq THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OF THE MAX FOR WHICH <br /> THIS RIPAR IB ISSUED,I M/ALL NOT EMPLOY RgSONo SLISJECT TO WOAXMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S NIPoNO Oq SUBCONTMCTMG BIONATURE CENTIHEB <br /> THE FOLLOWING: •I CEIRIFY THAT M TIE PEPoggMANCE OF TILE WOR FOR WHICN TNIB PER/R IS ISSUED,1 SNALL EMPLOY PERSONS SUBJECT TO U"O TRACCOMPENSATIONINDIDATURF [Mi OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL M NORMS IN ADVANCE FOR ALL REGMMMM INSPECTONS AT MOST ASS-MES. COMPLETE OM SUBANG AT LOWER AREA R'S ED. <br /> SISrrLX I -OSG I U!$� TIII. �. <br /> 1. NAMES OF STREETS OR ROADe WIFE. TO OR.OII=TIRE RgKATY.PLAN IDy. -A' BaSI. •M !tt <br /> Z. OUTLINE OF THE N1oPE1T',GIVNIO DIMENSIONS AM NORTH DIFIECTION. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on proMeED <br /> 3. DIMENSIONED OOTHNES AND LOCATION OF ALL EXIST"ANp MoMeD, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> STRUCTURES,INCLUDINO COVERED AREAS SUCH AS PATIOS,DAIVEWAYS,AM WAU S. S. LOCATION OF WELLS WRIRN RADIOS OF ONE HUNDRED FIFTY FT. <br /> ON THE PTOPERrY OR AOJOINMO PROPERTY. <br /> C+ 1 rc,POn� AOL\ �f 1X1q <br /> N <br /> 0 Q <br /> O <br /> DEPMTMMT USE ONLY <br /> Oreul Mw f D.1. Arr <,�T( <br /> peelbn BI A D.L. RmF IMpWIlen BY <br /> Oreween Imnslkn Br D.I. <br /> Cemmeel.. <br /> ACCOUNTING ONLY: AID/ <br /> FACT <br /> PE CODES FEE INTO AMOUNT ADMITTED CHEC M ASN RECEIVED SY DATE PNENIT/SMWCE REQUEST NUNSFA INVOICE <br /> •Dt <br /> Pub HeeAh Sew.-Emiro.173(1/97) <br />