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APPLICATION FOR WELLIPUMP PERMIT o b -! o [q, <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 9b201 988 <br />(2091401-3420 <br />NOR -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(CMRPMa In TriPR/Btll <br />APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION Ib MADE IN COMPLIANCE WIN SAN <br />JOAQUM COUNTY DEVELOPMENT TITLE.C_ 1.+ <br />,, CHAPTER 5-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC <br />FIEALT14 SERVICES, ENVIRONMENTAL HEALTH DMSION. <br />JOB ADDREeSroR .I � APNP 3Z3 A ICC b" clr! /— l C vV <br />PARCEL elzuAPNF <br />OWNER'S NAME-gAj1oL1jr/�^MAf ADDRESS /y A,1 PANE <br />.�A /�c-, <br />^/� ' <br />CONTRACTOR 1.�,� 1 -I� IAIt l .. -_ MOgEeB �-V ZT l , Q I W P. / �! <br />BUB CONTRACTOR ADDRESS LAco PION, F <br />TYPE OF NIELL/PUMP, RINEWWELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER t+ <br />1 aµ A❑WTION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL / <br />A°P�t H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL d <br />DUPE OF PUMPI <br />F-� ❑ OVT-OF-SERVICE WELL ❑ 0EOP1Y61CAL WELL # ❑ BOIL BORING --�, <br />lJ bESTINCTION: <br />FI�NT,B�DBEDBTLIIEAL YPE OF CO STRUCTIO SPEC K TION/ A <br />❑ate GOMES7ICIPNVATE ❑�-,OP���N BOTTOM / DIA. OF WELL EXCAVATION 1� w�. DIA. OF CONDUCTOR CASING p <br />{•14RAWL PACK/SIZE I TYPE OF CASINO/STEELRNC /L ppp(( V'` DIA. OF WELL CASINO VVV <br />❑ PUBUC/MUHICIPAL ❑ DRIVEN DEPTH OF GROUT REAL —t(L1f SPECIFICATION A q (� <br />❑ IRRIOATK)N/AO ❑ OTHER GROUT SFAL INSTALLED BY IL piIOVT GRAND NAME K/ p <br />CI MONNORINO 2 GROUT SEAL PUMPED: r ❑ Ns CONCRETE PEDESTAL BY GRILLER: [IN. S <br />APPROX. DEPTH J OO I LOCKING CIIEBTER BOXMTOVE PPE S 1 <br />PROPOSED CONSTRUCTICHIMMUNO METHOD: MUD ROTARY v AIR RDTARY AUGER CASLI OTHER <br />1 {RREBY CERTIFY TIIAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE OoNE M ACCORDANCE WITH BANREGJOAOUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND <br />7140 PERMIT <br />OF THE BAN ALL NOJOAQUT COUNTY. HOME OWNER T LICENSED AN'S CO SIGNATURE CERTNIES THE FOLLOWING: '1 CERTIFY THAT M THE PEWOOMANCE OF THE WORK FOR WIGCN \,J" <br />TISK OL L/IT IB ISSUED, 1811ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S CO SIGNATURE <br />LAWS OF CALIFORNIA.• CONTRACTOR'S HIRING OR BUB-0ONrK4CTINO SIGNATURE CERFBIES <br />THE FOLLOWING: • 1 CERTIFY T/ TII PERFORMANCE OF TIIE WORK FOR W/BCH THIS PERMIT IB ISSUED, 1 SHALL EMPLOY PERSONS BURJECT TO WORKMAN'S COMPENSATION LAWS Or <br />CAUFOIWIA.'////T111///////��I'A/,,,PEE1y,P,`1C//(� U T A Z HOLIM ADVANCE FOR ALL REGLMIFO IN,S/I TbN4 A(,*( '—))1A'// -MI COMPLETE DRAWING AT LOWER AREA <br />Mr.d X_ /-A- =-�y�� T11h L/ \tel Y F 2® <br />On• <br />PLOT MN ffk w t, Se— <br />i ( <br />. .. ..T.,.;.. ...i. . o. ...a. <br />131 i <br />CIPPAR—Imi, <br />AL <br />ACCOUNHNO ONLY: AID# FAC, <br />PE CODES FEE INFO AMOUNT REMITTED N #lCA611 RECEIVED BY DATE <br />P "TIevIVICE hEGUEST NUMBER <br />INVOICE <br />3 <br />D l <br />7 <br />L 732 <br />031733 <br />Pub. Health Serv. • Enviro, 173 (3/96) <br />