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sr'f _u <br /> APPLICATION ICOR WEWPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> y (209) 468-3420 <br /> LA( NON•REFUIIDABLE PERAfIT EXPIRES 1 TEAR Fp4M OATF ISSUEC <br /> ICemplet9 IB TrlpnesialAPPLICATION IS HETO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOM DESCRIBED,THIS APPLICATION IB MADE IN COMPLIANCE WTTII SAN <br /> JOAQUIN COUNTY DEVEL•%jt MM,ENT TITLE,CHAPTER 91-1118.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERIVICES,ENVIRONMENTAL HEALTH OMSI011. <br /> JOB ADDRE881OR APNI �QQtaC _? fj K S I,•. fy )-j CITY CITY �� �C,.� PARCEL SIZEJAPN/ <br /> OWNER'S NAMEt_�. ��1!1C�i_ ADDRESS !1 D <br /> PHONE <br /> coNrRAcrDR 'L. 1 ADDREeB��S 1$C'rS� ���;,�TuC��PNVNE.L��-17�'-7�.5�C� <br /> SUB CONTRACTOR ADDRESS LICS PHONE r <br /> TYPE OF WELLMUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR © CROSS-CONNECT REPAIR '❑ VAPOR EXTRACTION WELLr J <br /> i ❑New❑Repdt H,P, DEPTH PUMP BET FT. FIRST WATER LEVEL O <br /> RYPE OF PUMPS <br /> ❑ OUT-0F9ERVICE WELL ❑ OEOPHYSJCAL WELL A BOIL 801ONG B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION ipEC1FICAllaus A } <br /> ❑ 0MUSTAIAL ❑OPEN BOTTOM OSA.OF WELL EXCAVATION —UJtr �I DIA,OF CONOUCTOR CASINO O <br /> ❑ DOMESTICIPR IVATE ❑GRAVEL PACKMZE TYPE OF CASINOISTEELIPVC DIA.OF WELL CASINO, 1.0 <br /> ❑ R'JOLICIMUFBCIPAL ❑DRIVEN DEPTH OF GROUT REAL SPECIFICATION 1 V A k <br /> ❑ IRR IGATIONIAG ❑OTHER GROUT SEAL INSTALLED BYE re.-OA i L GROUT BRAVO NAME i f <br /> ❑ MONITOWNG GROUT SEAL PUMPED: I YM [If'. CONCRETE PEDESTAL SY DRIIiER: Y. ❑Na S <br /> APFROX_DEPTH �' ^J.�'1.. ! LOCKING CHESTER BOXISTOVE PIPE— <br /> PROPOSED <br /> S <br /> RRIOPOSED CONSTRUCTIONIDAIL1/NO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OCHER <br /> I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND 1J <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWM:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.- CONTRACTOR'S HIRING OR SUS-COMRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY T RFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORgMAN'S COMPENSATION LAWS OF y <br /> CALIFO THE APPLOC VST 11RS IIS ADVANCE FOR ALL REQUIRED tN5P�EtTIOftS AT I"01 aii�a27. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Stared X r Title S o_ll�� Date 7 ZZ ZAL <br /> PLOT FLAN Mfow to Saetet Sade 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSM SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PRIOPER Y,O11/M!Q WMENBIONB AND NORTH DIRECTION. EXPANSKIN OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. OM4EUMNED OUTLINES AND LOCATION OF ALL EX19TIM AND PROPOSED S. LOCATION OF WELLS WITIIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVETED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PRROPERTV. <br /> . rcP ...... <br /> .. :.... -. . .. <br /> , <br /> : . <br /> j <br /> v•�.T-.'"�-�:��"-t�....r=�� �` .w.�r�. �1���- _ _ _ err <br /> "DEYMTME?IT VaE ONLY q�j <br /> AppSaNlen Aeeepled BY Dna f a Mr <br /> 1 <br /> , Grein"PecOun By Date P f p Irnpeette�By Date <br /> Oeet,uetlen Inipeatlen 8 r}' Dole <br /> ACCOUNTING ONLY: AIDE FACE <br /> PE CODES FEE INFO AMOUNT REMTTED CHECKOICASH RECEIVED BY DATE PTA MRTISEHVICE REQUEST NILMBBR INVOICE <br /> k -2 -07-- <br /> Pub <br /> 0 Pub Health Serv.-Enviro.173(1/97) <br />