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APPLICATION FOR WELLI UMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICUN- <br /> ENVIRONMENTAL HEALTR DIVISION 4 I <br /> k-BOX 388,304 EAST WEBER AVENIJE.BTOCKTON,CA 95201.488 <br /> 12091 469.342 <br /> NDN•REFUNDAKE PERMIT EXP311E8 I Y Al FROM DATE ISSUED <br /> (Complete In Tllplk b) <br /> APPLICATION IS HERE BY MADE TO THE SAN JGAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOII STALL THE WOPEK OESCRBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br /> JDAOUBI COUNTY DrmoPmENT TR1LEE,pCHAPTER 8-i 115.3 AND T` � <br /> HE STANDARDS OF SAN JOAOUIN CNTY UPUBLIC HEALTH SERVICES.ENVIRONMENT1AL_HEALTH OrVIMN. <br /> JORADOREROMPAPNR 1 IOW.. WOfl� -�' <br /> c CRY PARCEL 81 v.. 'P G <br /> OWNER'6 NAME O ?� � .}. AobREaa L{ N. �er�a Sd'nckrt:r.PHONE/X31' L�L� <br /> COHTRACTDR 1rQ_ �lY� C�rA rLFj JL-T�(' . ADDRESSO ex Q I LIC* GIfi4 PHONE Iyb -IQ9.j <br /> SUB CONTRACTOR 1�h (11>aU�Tr '640 W. 4fk-P^nFn 4++.3k,16.Id-,Q'Q`.'� �•� <br /> ADDREBB LIC* yij:ia... <br /> PHONE o. <br /> TYPE OF WE_ MP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONROMMO WE L i ❑OTHER <br /> ❑INSTALLATION ❑WEI.t SYSTEM REPAIR D CROSS-CONNEC REPAIR ❑VAPOR ExTRACTIOH WELL/ <br /> ❑H—❑Re.II H.P. DEPTH PUMP BET FT. FIRATER LEVEL O <br /> (TYPE OF PUMP; <br /> ❑OVTOF-SERVICE WELL ❑GEOPHYSICAL * BOIL BORWO g <br /> ❑ <br /> DESTRUCTION: - <br /> OEM E YPF OF W CONggLICT[ON fPECIFIC IDN A <br /> ❑MOUSTMAL ❑opt"BOTTOM DIA.OF WILL EXCAVATION DIA.OF CONbUCTOR CASINO O <br /> ❑DOR/ESTICIITSVATE ❑OFAVEL PACR'a12E TYPEOF CASMO/STEEUPVC DIA.OF WELL CAB[NO D <br /> ❑PJRUC'MUMCIPAL ❑ORVEN DEPTH OF GROUT REAL SPECIFICATION p <br /> 11 IRROATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME E <br /> ❑MOW" <br /> om"O OROUT SEALPUMPED:❑Yw N. CONCMF PEDESTAL 8Y DA1UER:❑Yw ❑Ne 5 <br /> APPROX.OERTI/ LOMPM CHESTER R XIITOVE MIT / _�j 3 <br /> PROPOSED COMSTRLICTIONICRILLINO MFTHOO; MUD ROTARY AM ROTARY AUGER CASTE OTHER 6Ptp Pnd3r- <br /> 1 H"RV CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AHO THAT 1111E WORK WILL Sr DONE IN AC OF0ANCE WITH SAN JOAGU1N COUNTY OFIDMANCE8,"ATE LAWS.AND"a AND <br /> REGULATION*OF THE RAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SNINATURE CERTIF 1 THE POLLOYNNO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> S THIS FEFMIT IS MAUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS F CALIFORNIA.- CONTRACTOR'S HIRINn OR SU"ONTRACTn10 81ONATURE CERTIFES <br /> TRE FOLLOWING! 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS Ir VIED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPSNRATION LAWS OF <br /> CALIFORNIA.' THEA AMT MUST CALL 24 HOURS IN ADVANCE FOR ALL FIEOIBRED IMPPECTIONS AT 14x4004{22, COM"E,1p. 'AnHO AT LOWER AREA PROVIDED, <br /> Sleneu X V`�f-- TIeI. {�1 <br /> On. <br /> PLOT PLAN 0—f.Se.l.l Sole <br /> 1. NAMES OF STREETS S NEAREST TO OR BOUNbINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR pROPOSID <br /> 2. OUTLINE OF THE PROPERTY,ONING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DI8POSAL RYSTPMe. <br /> 2. WMENBONED OUTLINES AND LOCATION OF ALL EXR11"O AND PROPOSED S.LOCATION OF WELLS WITHIN RAMS OF ONE HUNOREO PIPE FT. <br /> STRUCTURES,STCLVDDYO COVERED AREAS SUCH AS PAVO8,DRIVEWAYS,AND WALK$, ON THE PROPERTY OR ADJOINM PROPERTY. <br /> DEIMTMENT USE ONLY <br /> Anpn.nlen Aee.pl..d BT <br /> Oran Swpeetlen BY Dn. PRe,q I�rpenlen by bele <br /> Oe.lnwFlen Uweeerlen Ry <br /> One <br /> Cemmem.: <br /> ACCOUNTING ONLY: Am* FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKNICASH FiEB <br /> CYED b BY TE F98eGTlaERVICF REGKIFJIT NUMRDI INVOICE ' <br /> Sit u 33L . ftwolk l o o <br />