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APPLICATION FOR WELL)PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV��' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX SW VX FAST WEBER AVENUE,STOCKTON. CA SMI- 88 <br /> 1209) 468-3420 <br /> NOWNEFUNDABLE PERMIT EXPIRES I <br /> EXPIRES FROM DATE ISSUED <br /> (COMP10116 IN TrIpfintel <br /> APPLICATION is RFfT BY MADE TO THE SAN JOAQUp;COUNTY"OR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED,THIS APPLICATION is MADE IN COMPLIANCE WITH CAN <br /> JOAO"COUNTY DEVELOPMENT TITLE,C14APMO-1 115.3 ANO THE STANDARDS OF SAN JOAGUINCOUNTY PUBLIC HEALTH SERVICES.ENVIROHMIVITAL HEALTH omsio", <br /> '5��JOIB ADORESSMA APWI_,,�Z-M 'V <br /> PARCEL SIZEIAP040 <br /> OWMA's NAME AOORqN6&fa&-A, P PHONE 0 Ap <br /> Zu PHONE# <br /> I"CONTRACTOR ADDRESS fl y �;&—,2-0-7 P040HE I <br /> TYPE OF WIEIX� <br /> (3 NEW WFU 0 REPLACEMENT WELL. ❑ MONIT*Alma WELL$ 13 OTHER <br /> 1:1 INSTALLATION 13 WELL SYSTEM AvrAm <br /> 0 me-0 neveb H.P. 13 CROVS-CONWCT REPAIR 0 VAPOR EXTRACTION WELL IF <br /> (TYPE OF PUMPI DEPTH PUMP SETFT. FIRST WATER LEVEL <br /> 0 om-or-SERVICE WELL 0 GEOPHYSICAL WELL* soft BoAlm --v—/ a <br /> Cl DESTRUCTION. <br /> c 62 <br /> rip-ANVI II%lQ V10 <br /> =37 M <br /> 0 INDUSTRIAL 11 OPEN BOTTOM DiA,OF WELL EXCAVATION OW OF CONDUCTOR CASING AM '11 D <br /> 0 OOME9TICJPR1VATE 0 GRAVEL PACKMWZF TYPE OF CASMOISTEELIPVC—A14 OTA.orWELL CASING-- &A 0 <br /> 13 PUBLIC MUNICIPAL El DRIVE" DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑ MAIGATIONMO XOTHEA PP7— <br /> GROUT BEAL INSTALLED BY GROUT BRAND NAME ZA27,W-04;M1!&A`Z— E <br /> MDrRTORIHNO onotrr SEAL PUMPED: 0 ve. Erw CONCRETE PEDESTAL BY vialtuRi 13 Y. Erk. S <br /> APPROX. LOCKING CHESTER BoXmTovE PIPE S <br /> PROPOSED CONSIMIXTIONIVAILLING MET"W. MUID ROTARY AM ROTARY <br /> AUGER—CAME OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIM COUNTY ORDINANCES.STATE LAWS,AND PUL <br /> REGULATIONS OF THE BAN JOAoLAN COUNTY. HOME OWNER on LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWM:'I CERTIFY THAT IN THE PERFORMANCE ES AND <br /> THIN PERMIT IN ISSUED,I SHALL NOT EMPLOY PERSON$SU"C Rr AMANCE Of THE WOW FOR~C" <br /> T To WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S sMNNO OR S-CON CTIN <br /> THE FOLLOWING,, *I CERTIFY THAT IN THE PERFORMANCE of THE WOW F014 WHICH THIN PERMIT 19 ISSUED,I IIHALL EMPLOY PEaso"a e BU TRA 0 SIGNATURE CERTIFIES <br /> CAUro SUBJECT TO WORMAN'S COMPENSATION LAWS OF <br /> X=;I;T.'� UST ALL a14"Otfiff IN ADVANCE FOR ALL REQUIRED WSPIXTION4 AT 92"14004422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> allm"d /L�— 1 0 D". y-7—!�q <br /> \111/ PLOT PLAN IDaw to Beef*)Be." <br /> 1. NAMES Of GTREIETS OR ROADS NEAREBT To 0.BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on ,Mpopto <br /> 2. OUTLINE OF THE PMPEATY,OMM DIMENSIONS AND NORTH OMCTIoN, <br /> 3. DIMENSIDNED OVTtjmFS AND LOCATION OF ALL EXIST, AND PGAG6FO EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> "a S. LOCATION OF WELL8 WITHIN RADIUS OF ONE HUNDMO FIFTY M. <br /> STRUCTURES.INCLUDINO COVEFED AREAS SUCH As PATION,DRIVEWAYS,AND WAIXG. <br /> ON THE PROPERTY OR ADJOINING PROPERTY. <br /> .......... <br /> .77. <br /> .......... <br /> ,e DEPARTMENT Use ONLY <br /> Av#%rwtlen Avo led By F�(,,,.'ITf��'41 <br /> Del. Am. <br /> D*tv Pkom It-veaden By <br /> Data <br /> Damnictleft Impeallan By_ <br /> Dole <br /> CemmeMatPH S 1:6 ttD <br /> ACCOUNTING ONLY: LAnm <br /> - I ERCT <br /> PE CODE$ FEENIFO AMOUNT"VATTED <br /> VHECKOXASH RECEIVED NY DATE PIMOT)SERVICE!REGUEST NUMBER INVOICE <br /> cit t�28� 1 <br /> 2 at u <br /> Pub.Health Sm.-Er&*o.173(3/96) <br />