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PAY CJI EN I' <br /> .APPLICATION FOR WFLLJPUM w EIVED <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIONA 95202 t <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 T�•�( <br /> (209) 468-3420 5 N JC A. C <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM RATE ISSUED <br /> ENVIFONMENiNL HCES <br /> EALTH ERVIDIVISIOPI <br /> (Cempl11b In Triplicate) <br /> APPLICATION 19 HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR( DESCRIBED, THIS APPLICATION 18 MADE IN COMPLIANCE WTTIt BAN <br /> JOAQUIN COUNTY <br /> DEVELOPMENT TIR(�E`,`CHAPTER <br /> 9- 1115.3 <br /> - 11115.3 AAND THE STANDARDS Of BAN JOAQUIN COUNTY PUBUC HEALTH SERVICES, ENVIRONMENTAL HEALTH D <br /> IV <br /> IS1II1O11 NI. <br /> JOBADDRESSMRAMN - qUS ACIFlC. LVFNVC , CITYU PARCEL SIZE/APN/ <br /> OWNER'S NAMEPAI , cCFlVS ` ( JCAA�� CASIfU ADDRESS �yCIJ rIfClC _ 0Y1VGPHONE # <br /> T ( . AODRFSS L/U GA/ IV INJfI IV6 UC/ ` 12 PHONE <br /> 'J - �J"I�L�OCOMMCTORAlANl2 � I 15 <br /> V <br /> BUB CONTRACTOR ADDILEBS Uc! PHONE / <br /> RAW.. Z Mw , � <br /> TYPE OF WELL/PUMP: . NEW WELL ❑ REPLACEMENT WELL MONITOMM WELL / AA ,$ M Va".1a ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROB"ONNECT REPAIR ❑ VAPOR EXTRACTION WELL / ✓ <br /> ❑ Navy ❑ Repair H.P. DEPTH PIMP SET_R. FIRST WATER LEVEL O <br /> (TYPE OF PIMPI <br /> ❑ OUT-OF-SERVIOE WELL ❑ GEOPHYSICAL WELL / ❑ ROIL RORINO S <br /> ❑ DEBT RUCTION: cc�� 11 (� <br /> STIMICTION <br /> ONE <br /> ❑INTENDED <br /> DUSTRIAL ❑ OPEN BOTTOM DNOF WELL CAVATIONTI <br /> INDUSTRIAL AX6 TG IC DIA. OF CONDUCTOR CASINO IV / A O <br /> ❑ DOMESTICIAVVATE XORAVEL PACK/SIZE I n:L 0 A TYPE OF CABINGISTEEU�1 1 V C. DIA. OF WELL CASING O <br /> ❑ RIBUCIMUNICIPAL ❑ DRIVEN DEPTH OF DROLL BEAL v I [-c.. 1 6 SV i- :. N F'J SPEC IC FICATION SA !0 " , U R <br /> IRRIGATION/AG ❑ OTHER GROUT BEAL INSTALLEDBYAE m'1 M � TI+ DAD GROUT BRAND NAME LR71 �D E <br /> AMONITORING GROUT BEAL PIMPED: ��Ys ❑ NO T] CONCRETE PEDESTAL BY DRLLER:�Yr ONO S <br /> APPROX. DEPTH <br /> OCK Smell /STOVE RPE <br /> PROPOSED CONSTRUCTIONA)RIWNO METHOD: MUD ROTARY MR ROTAIRY AUGER CABLE OTHER <br /> I MatEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AN; <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNEn OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 181SSUED, 1814ALL NOT EMPLOY PERSONS SUBJECTTO WORKMAN'S COMPENSATION LAWS DFCAUFORNIA.' CONTRACTOR'S HIRNU OR BUB{OWMCTING SIGNATURE CERTIREB <br /> THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORIG APPS COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL C24 ND TIS QUIRED GIN�SPECTRONG AT 120111440) 2a. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Btened R / TRIM Jt NI ,Q -7 1 � /R Z - l; <br /> % IN ADVANCE FOR ALL REL <br /> C t- : L I '> Date -j V �i/ <br /> PLOT PLAN RAaw to Bowel Scale to <br /> I . NAMES OF STREETS OR MAD8 NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE outror . SYSTEM On PROPOSED <br /> 2. OWUNE OF THE PIIOPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL 8YBTEMB, <br /> G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 11, LOCATION OF WELLS WITHIN RADIUS OF ONE NUNOMD FIFTY IT . <br /> STHUCTUREB, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> .__ <br /> DEPARTMENT USE ONLY /� p <br /> Applloatlan Aaemted By <br /> Data �o —�- 4 Arae Olo ZS <br /> mem Irs a tion Br Dote Rang Inspection Rv Data <br /> D"Umfian Inspection Br / Data <br /> I amm 7N.u�T��9 £ io . � �� CU5/amu/ : Y/iCC�E losto9 �f� oy <br /> ACCOUNTING ONLY: AID# FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RECOVED RY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 1388 9 �3o-2w 01 Ll3 <br />