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APPLICATION FOR WELLIPUMP PERMIT + <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERs <br /> ENVIRONMENTAL HEALTH DIVISION <br /> RO. BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA gMi-388 <br /> (209} 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete In Triptkate) <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1115.3 ANO THE STANDARDS OF CAN JOAOUIN COUNTY PPUUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORESSIOR APNf ` qtr � )j•[A.!I-{ �'6j' Z� re- CtrrQT��JV`] L}. PARCEL SIZEfAPNI <br /> OWNER'S 1A.1t."I.d'P""Lan, &13pq <br /> CONTRACTOR� t/L may, PHONE! 7-30 ✓ <br /> JJ �/ 1 -�_�u+ /�� ,., ADDRESS L1Cf�f�Lf ?,Z,7_p110/N�E+1 <br /> SUB CONTRACTOR ` 1 S Ci�4ClXi l►tom �e-,L C��_ ADDRESS C�y -eg;�-p <br /> TYPE OF WELLmUMP: ❑ NEW WELL ❑ REPLACEMENT WELL Eg MONITORING WELLf �❑f�OT14ER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR L1CFtOGS-CONNECT REPAIR LLVAPOR EXTRACTION WELL f- <br /> ❑New❑Repdr H.P. DEPTH PUMP SET FT. FIRST WAVER LEVEL O <br /> (TYPE OF PUMPI <br /> � <br /> 11OUT-OF-SERVICEWELL 11 GEOPHYSICAL WELL+I El COIL sortma a <br /> Er <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION— <br /> ❑ <br /> 1--�� DIA.OF CONDUCTOR CASING A OOMESTICIPRIVATE L�pRAVEL PACKISIZE 01 Z TYPE OF CASINGISTEEt45*;-2 DIA.OF WELL CASING ZN O <br /> ❑ PUBUCSNUMCIPAL ❑Mn1VEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ 1RRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED By BRAND NAM <br /> NE F <br /> MOMTORING / GROUT SEAL PUMPED: [9<. ❑No CONCRETE PEDESTAL BY DRILLER:�J yow Ne 5 <br /> APPROX.DEPTH_J�� { LOCKINO CHESTER BOXJSTOVE PIPE S <br /> PROPOSED CONSTRUCTIONIORILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 111£9ESV CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK VALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AHD <br /> REGULATIONS OF THE SAN JOAOUtN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> 114119 PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR glu"0141RACUNO SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAI IN THE FfRFORMANCF OF THE WORK POR WHICH THIS PERMrT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'!COMPENSATIONLAWS OF <br /> CAUrORMA.- THE`PPl1C T MUST CALLMIN ADVANCE FOR ALL REGUIRM INSPECTIONS AT 12001-"84422. COMPLETE DRAWING AT LOWER AREA PiOVJDED <br /> Blpned X THIS <br /> �G�� or- <br /> "r�"`r- Date�fye <br /> PLOT PLAN{Draw to Bade)$eale 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROP'HFV, A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROIpSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> ]. DIMENSIONED OLI?UNEB AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WrrHIN RADIUS OF ONE HUNDREO FIFTY FT. <br /> STRUCTURES,INCLUVWO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> --- �� - �-- ,�n� �•r �_. _ DFDART,_- ENT�_E.ONLY _ _ -_ _ _ <br /> Apprketlen Aeaepted A1y ' <br /> E bele Area <br /> GmA Inrpeerlen or Date Pump Inspeetlen By Date <br /> O-Irm lon Iner-Oen By <br /> Dere <br /> CemmerK�: - <br /> i <br /> ACCOUNTING ONLY: ALD/ FACE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKVICASH RECEIVED By DAT PE RMITIEERVICE REOUEST.NUMBE R INVOICE <br /> Deco i5? is <br /> Pub.Health Serv.-Enviro.173(3/96) <br />