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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 988,304 EAST WEBER AVENUE,MCKTON,CA 95201388 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> ICempl&t&In Trtpl'M&UI <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND.THE STANDARDS OF SAN JOAOUIN COUNTY FHBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR AR// -Z!/ A(Jy. /-S leVV- �� CIT-I,y,y� /lam- ,,,+1 /j PARCEL SREIAPN# <br /> OWNER'S NAME. <br /> �1t�/(l5e7I W /f./9W,-iG�f J i ADORESB�LY/// %ZJL.i�. /�.Q/� /p PHONE'r q�j-�q�/ <br /> /,t.(L4Z/KLe L /!l �( µL�/ � �LrL•/ (/0PHONE I/16-G'Lfi/ <br /> cO1RRAcroq !! /y7[p'��i/`•✓AyL�t ADDRESS - - <br /> RVe CONTRACTOR �L-7 L' •lir'�/4'/TiW /�c— ADDRESS 3 IrF lvrfy Uc 5 (�lh. PHONE <br /> TYPE OF WELLIPUMP: NEW WELL ❑REPLACEMENT WELL 11 MONITORING WELL.�� ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL <br /> 11P <br /> H—❑11 O H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> RVPE OF PUMP) <br /> ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL• CJ 601E BONN. IZ-� R <br /> ❑DESTRUCTION- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION ' <br /> �T A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION___..._;?/ DIA.OF CONDUCTOR CASINO ? O <br /> ❑DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC Ty� DIA.OF WELL CASING 2/,/-/1 O <br /> ❑PVBUU <br /> CIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SMCIFICATION R <br /> �❑IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY y GROUT BRAND NAME A'l Ifp' E <br /> J! MOMTONNO GROUT SEAL PUMPED:❑Y. [FIN. CONCRETE PEDESTAL BY DRILLER:❑V« e S <br /> AP X.DEPTH LOCKING CHESTER BOXMI.OVE PPE S <br /> PROPOSED CONSTRUCHOMRMSWNQ METHOD: MUD ROTAM AIR ROTARY AUGER L,"— CABLE OTHER <br /> I HE4EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNrY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS OF T14E SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'4 CERTIFY THAT IN THE PERrORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUB.CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFOjiM�N ADVANCE NCE OF THE FOR ALL REOIAREO IM/►ECTNIN&AT ISN11u�=f W FOR WHIC"THIS PERMIT 10 ISSUED.I SHALL EMPLOY PERSONS <br /> D/RAWiNO ATTTO LOWER AREAA &ATOM LAWS OF <br /> CALIFORM,-A-j 1. .A►//P�'T�AMT TCjL,Li(/y�IE /SONS OM PROVIDED. <br /> Bland XTlti. Ll-�/ <br /> ROT PLAN IOr.w to 0".)S.d. 'to ' <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> i.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTINO AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,MICLUOING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> OFJ'MTMIiMT USE oMLr 9 <br /> APPI..tlen Aee.ptd By.Y 1`� D.,. �3- L <br /> --PVT A­ <br /> G­I-P..11—By D.b P—P In.Prtlan BY Do. <br /> D«t,ixtlen I—P-11—By <br /> Da. <br /> C......, Apf?rw&�v4- c�lwu'T jNA5 S�b�� �b Wor11, PIGi� y�1od�{�t*y� oursl��s✓b9 J <br /> cn' LLLVL hM4Q LI oY r W2�6 oetls <br /> ACCOUNTING ONLY: AIDS PACO <br /> PE CODES FEE INFO AMOUNT REMITTED CFMCKSICASH RECEIVED EY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 1 (��l I•Z3b1� Z <br /> Pub.Health Serv.-Enviro.173(3/96) <br />