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titles ''PAYS 1EN <br /> APPLICATION FOR WEWPUMP PERMIT ;-e e-CP,*'y$'0- <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES JAS[ 12 1999 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 :CA N7Y <br /> PUf?Ut1 Gi1LTH SEI- CES <br /> (209) 468-3420 '.,,jv;poNANIEiJTAL HEALTH DIVISION <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete is TRIpRe$bi <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAOUII COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TRIS,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY(PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMMON. <br /> JOB AOORESSMRQ -0.114 <br /> 1 0 CITY <br /> LC a 1 (� L' / ,� PARCEL SIZE/APNF 2 3 2 <br /> OWNER'S NAME f C I Cf 110d l ADDRESS 7­11 t `N�s37'. r.t art i I'Ll . �I-Od PHONE.J l7-670 G <br /> CONTRACTOR A Vdu Clc( �"O fih UA Tv%1 RIG♦1.(1,11, -Z 14 f_ ADDRESS 4007` N..W;I 'Di1 IMa Y5TIA $011 PHONE -1 -106 4. <br /> BUB CONTRACTOR SCi I i rR0r lttla S.ar UiC�f��N.< _ ADDIIES$'68JT4 FraifVIJg� 15QC.UCs J4316f P5111 1� <br /> TYPE OF VVELL/PI1MP. ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL/_1 __ ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑N.❑Repa4 H.P. DEPTH PUMP eET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELLS M BOIL BORING R <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ,I A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKmrZE TYPE OF CASING/STEEL/PVC OIA.OF WELL CASINO D <br /> ❑ PVSLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL T. P• SPECIFICATION y R <br /> ❑a� IRRIOATION/AG ❑OTNER GROUT SEAL INSTALLED BY ''NA IM f L GROUT BRAND NAME t)Y 1�Q�C4 f <br /> 51 MoMToRING // f GROUT SEAL PUMPED:❑Yw ❑N. CONCRETE PEDESTL.ABY DRILLER:❑Yw (31N. s <br /> e <br /> APPROX.DEPTH O LOCKING CHESTER BOXMTOVE PIPE s <br /> PROPOSED CONETRUCTION/DIELUNG METHOD: MUD ROTARY AIR ROTARY AUGErt__K_CABLE OTHER <br /> I"MBY 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 <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CAUFOrMA.' CONTRACTOR'S MMNO OR SUS-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMIANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS SN ADVANCE FOR ALL REGUIII®INSPECTIONS AT("1" <br /> 4/0044p12�. COMPLETE DRAWING AT LOWER AREA PROVIDED. o Io <br /> R$,»d X 1,yL1, "/�iC.1�tIdAl►'1 T. S:N.1C, S ht 6,ytol i 5l / on. 1 �QN 1 1�Q T1 <br /> PLOT RAN(Draw t.so"B.M. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF ROUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.011IMM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXHITING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STR)CTURES,INCLUDING COVERED AREAS SUCH M PATIOS,DRVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINIM PROPERTY. <br /> .. _ .. _ _ <br /> i .. :. .......... ... <br /> ` DEPARTMENT USE ONLY 2 <br /> ApPN on Ao~ed BY .Liww f__ � DM. 7 Mw <br /> (I'MA kope.tbn By '/\GSI/vet!//✓1 Dan Pu_w Irw..etlen 8y Date <br /> Oaatnwtlen Itwwpaetlen 8r Date <br /> Cannw.wa• <br /> ACCOUNTING ONLY: AIO/ FAC! <br /> PE CODES FEE INFO AMOUNT fMOTTED CHECKS CASH REC9VED SY DATE P9VWT/$9MCS REQUEST NWNM INVOICE <br /> Pub yeafth Serv.-Errviro.173(1/97) <br />