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w- —� APPLICATION FOR WELLIPUMP PERMIT <br /> SAN_ JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> ENVIRONMENTAL HEALTH DIVISION 11 <br /> `--., 304 EAST WEBER AVENUE, STOCKTON,CA 95202 <br /> (209) 468-3420 <br /> NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FRO1R DATE ISSUED <br /> ICDmpNt&in TripReetrl <br /> APPLICATION 19 HERE BY MADE TO THEM SAN JOAQUCOUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.TF89 APPLICATION 18 MADE IH COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-}.1,15.3 AND THE STGANDARDB OF SAN JOAQUIN COUNTY���D LTH EFMCEB,ENVIRONMENTAL HEALTH DIVISION. <br /> ;I��f S 3 c �Z�Z!Z CITY SS PARCEL 91Z APN <br /> JOB ADOMOSlOR APN/ C�'J �� !�� /] L <br /> �Q 9�d/IAC AbbfSE68 ?O• �f 0)(01OP PHONE <br /> OWNER'S NAME <br /> CONTRACTOR Jy <br /> SSI �L r Ze/ /5 ��� ADORED. f� RJCr �PHONE 9-72 74 <br /> OwCONTMCTOR ,ll 11 IL-c�5� ADDREBBC dna Cr7 LPCs PHaNEI <br /> r <br /> TYPE OF WELLMUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL. EI OTHER <br /> 11 INSTALLATION WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r <br /> 13New❑R.Pd. H.P_ DEPTH PUMP SET FT. flRBT WATER LEVEL O <br /> (TYPE OF PUMPI ❑ ONT-0E-SERVICE WELL ❑ GEOPHYCICAL WELL r ❑ BOIL BORING R <br /> ❑DESTRUCTION:: <br /> INTENDED UBE TYPE OR WELL _ CONSTRUCTION SPECIFICATIONS A <br /> F ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION -IAC DIA.OF�CONDUCTORCASINO./ e D <br />+ ❑ DOMESTICMMVATE ®GRAVEL PACX1S12&*3 TYPE OF CASINGISTEELIPVC C DIA.OF WERE CASING ~I/IC D <br /> ❑ PUBLICAaUMCIPAL ❑DRIVEN DEPTH OF GROUT 6EAL ec — CIFICATION S R <br /> ❑ IRRtOA11ONJAG ❑OTHER GROUT SEAL INSTALLED BY y►+ ROUT BRAND NAM la Gtl E <br /> ❑ MONITORING Q rL GROUT SEAL PUMPED: ❑Ya. wme CONCRETE PEDEST SY DRILLER-1I Ye. [IN. 5 <br /> APPROX.DEPTH .J� eG` LOCKMO CHESTER BOXISTOVE RPE S <br /> PROPOSED CONSTRUCTIONMRILLINO METHOD: MUD ROTARY AIR ROTAFIY AUGER _CARLEC��ARLE OTHER <br /> p <br /> I HE9E9Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COV ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT THE PERFORMANCE OF THE WORK FOR WHICH <br /> - <br /> THIS PERMIT IS 189UED,t SHALL PERBONB SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CALIFOFSRA.' CONTRACTOR'S M OR SUB-CONTRACTING SIGNATURE CERTIFIER <br /> THE FOLLOWING: ERTI TI PERFORMANCE OF THE WORK FOR WHICH TWO PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS BU CT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' C 24 IN ADVANCE FOR ALL REGUBRED INSPECTIONS AT 126r 4ba423. COMPLETE DRAWING AT LOWER AREA PROVIDED.1 <br /> Signed X Tltl.-21 <br /> PLOT LEAN BM.w to SoM.l Beat. 'to <br /> 1. NAMES OF STREETS O ADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPE ,OWING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DI9P08AL SYSTEMS. <br /> 3. DIMENSIONED OUTLINE6 AND LOCAr OII OF ALL EXISTING AND PROPOSED S. LOCATION OF WELL8 WITHIN RADIO&OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIO6,DRIVEWAYS.AND WATXS. ON THE PROPERTY OR ADJOSVING.PIOPERT,Y - <br /> .. <br /> DEPARTMENT US!ONLY <br /> Application Aee.pl.d By P' S <br /> Date <br /> Grout Irnpeellen By Dote S Pump 1n.P.otlen By Data <br /> De.trerellen In.Peetlon Bye <br /> b.ee <br /> Comment.: - <br /> ��:ti d1A La 2 •F 3 <br /> 4 <br /> ACCOUNTING ONLY: AlDr FAC! <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS SN RECEIVED BY DATE PERMITISERVICE REOVEST NUM&ER ;INVOICE <br /> Pub Health 5erv.-EnvirO.173(1/97) �c I l{ (,'d 3(-),r- a t s�/I/` SA4 <br /> - - u (3(-),r+ <br /> R1 r..-Lfi -4J 01 g a a.0 <br />