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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Comphita IS Triplicalls) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOA(MN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUINCOUNTY DEVELOPMENT TITLE.CHAPTER 9-111 S.3 AND T04C STANDARDS OF SAN JOAOUlINCOUNtY`PURL?C HEALTH SERVICES,ENVIRONMENTAL HEALTH DrAGION. <br /> JOB ADOREII100A.APNF I t Li 1 5 4100 <br /> ROaA C. 5 locklovA PARCEL SIZVAPN# <br /> OWNER'S NAME 'pe '14y' L ADDRESS PHONE 0 <br /> CONTRACTOR Advovr-cd JCjjr'rj4"_ AOMS8 100�' k/. W:15oii Wipt.ICS6502'27 rHoNE'q6'L7-10r'6 <br /> SUB CONTRACTOR ADCM9G LIC9 PHONE# <br /> TYPE OF U4PUMP, 0 NEW WELL 13 REPLACEMENT WELL MOM'TORING WELL 8 0 OTHER <br /> 11 INSTALLATION 0 WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL <br /> 13 N.0 P.O.1, H.P. OEPT H PUMP SET FT FIRST WATER LEVEL 0 <br /> IT YPf OF PUMP) 13 OuTor-al"we WELL ❑ GEOPHYSICAL WELL I QL Sort,BoruNG 9 6' 9 <br /> 0 DESTRUCTION: <br /> INTENDED use TYPE OF WELL CONSTRUCTION SPECIFICATIONS f. A <br /> 0 INDUSTRIAL 0 OPEN worrom DIA.OF WELL EXCAVATION 0 OIA,OF CONDUCTOR CASINO <br /> 0 DOPAKSTICMIRIVATE GOORAVIEL PACXISI" 'TYPE OF CASINGISTEELIPVC e- . OIA.OF WELL CASINO 2 <br /> ❑ <br /> PUBLICIPMUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL I I 'I-,P, SPECIFICATION -- 15C 14(2 ft <br /> ❑ MMOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY f41ft&A4 A, GROUT BRAND NAME_fL),- 10 kci <br /> MONITORING OROUT SEAL PUMPED: [11 Yea ON. CONCRETE PEDESTAL SYDAILLER:Oyes (NN* S <br /> APPROX,DEPTH- 6 LOCKING CHESTER SOXXTOVE PIPE <br /> PROPOSED CONSTRUCTIOMMMULING METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br /> I"MOY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN lOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RMS AND <br /> nVOULATIONS,OF THE GAN JOAOUtN COUNTY, HOME OWNER OR LICENSED AOENT,g SIONAWRE CERTIFIES THE FOLLOWINoi'I CERTIFY THAT IN THE PCWOFqPAAP#CIE OF THE WORK FOR WHICH <br /> THIS PERMIT 10 ISSUED,I 804ALIL Nor EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.' CONTRACTOR'S HIRING OR RU"ONTRACTING SKINATURE C(FRrlIrtE <br /> THE FOLLOWING: 'I CERTIFY THAT NU THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT to Isswo.t SHALL EMPLOY PERSONS SUBJECT to INCHROAAM'S'COMPENSATION LAWS 0; <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUiRED ratsprCytoNs AT 1308}485.842?- COMPLETE VPAiAnM3 AT LOWER AREA PROVIDED, <br /> sto-w x ` t,(/ tdtyz:El THIS 5"%�07 i?Q _O.. <br /> PLOT PLAN IDow to Sotol.1 Seat* <br /> 1, NAMES Of STREETS OR ROADS NEAREST TO OR BOUND(NO THE PROPERTY. 4, LOCATION OF HOUSE eEwAoe 048ro8AL SYSTEM on PnomsEv <br /> 2. OUTLINE Or THE PPOPEWY,OrV*M DMENSIONO ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 3- DIMENSIONED QVTLfW,$AND LOCATION OF ALL EXISTING AND PROPOSED <br /> S. LOCATION OF WFUR WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES,IINCLUOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJORM40 PROPERTY, <br /> ........... <br /> -.A <br /> DEPARTMENT USE ONLY Lamm-=E� <br /> :Si <br /> 0,"I—poeoe.or vat- <br /> ' P-0 Impact- <br /> 0-111-tto.Impoctio. 7---�r— Oat# <br /> co—ems: D.I. <br /> ACCOUNT/NO ONLY: AIDS <br /> rAC# <br /> PE CODES FEE INFO <br /> AA*O UNT REMITTED CHECIUMASH RECEIVED my BAT PSMAT/4""ClE REQUEST NUMBER <br /> INVOICE <br /> Pub Lieam se(v.-Enviro. 173(1/97) <br />