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lO.3o <br /> APPLICATION FOR WELLlPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES J Z <br /> ENVIRONMENTAL HEALTH DIVISION �y, <br /> P 0 BOX 388,446 N.SAN JOAQUIN ST., STOCKTON,CA 96201-386 W5D5 j <br /> R09) 4883420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAl FROM DATE ISSUED <br /> IC{RpMt{in TrIpl{ut.l <br /> APPLICATION IS HERE BY MADE TO THE SM JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMAJ^NCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TTTLE,/CHAPTER 9-1 S.3 AND THE STANDARDS <br /> OJAN JOAQUN COUNTY R C HEALTH SERVICES,ENVNgNMENTAL HEALTH DIVISION. <br /> JOB ADORESSJORI A.^N/ lO��( I �f Q�'�Q•y1�S r/��CITY I'' P AZE(APNf_ <br /> OWNER'8 NAME �\ ADDRESS If <br /> CONTRACTOR jf FE SS • _..E,-Z27- <br /> DUB <br /> HONE7Z27BUB CONTRACTOR ADDRESS L1Gf _PHONE <br /> TYPE OF WFUtPUMP: NEW WELL ❑REPLACEMENT WELL ❑MONIToRNO WELL/ ❑OTHER <br /> �I/r/'/ ❑IPf,OYALLATION ❑WELL SYSTEM REEPPAR{ Cl CWSSCONNECT REPNR ❑VAPOR EXTRNTLDN WELL f J <br /> 4/ {•�G•/Nµ❑P-1, H.P. :}' DEPTH RUMP SET FT. FIRST WATER LEVEL O <br /> ITVPE OF PUMPI N <br /> ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL f ❑ SOIL SWONG B Ir- <br /> ❑DESTRUCTION C+ <br /> INTENDED USE �TYK IE—L CONST LUCTION 8P 11FICATION{ 1 A <br /> ❑NDUSTRIALOIC PEI+BOTTOM DIA.OF WELL EXCAVATION DIA OF CONDUCTOR CASNGI•� D ^ <br /> ❑DOMESTICIMVATE ❑GRAVEL PACgiNZE TYPE OF CASINGWEElNVC D',A.OF WELL CASINO I�[.HE D 1^•U <br /> ❑W MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME P'1 f <br /> ❑MONITORING GROUT SEAL Pl1MPED.❑Y.ICONCRETE PEDESTALRY DRILLER:/RY.. ❑N. S <br /> W C <br /> A 4"CX.DEJRH LOCKING CHESTER DO)VOTOVE RPE_ J: f <br /> PROPOSED CONSTRUCTIONADRUING METHOD: MUD ROTARY— AIR ROTARY AUGER _CABLE OTHER <br /> 1 HEREBYCERTIFY THAT 1 HAVE PREPARED THIS APPLJCATION AND THAT THE WOR(WILL BE DONE N ACCORDANCE WITH SAN JOAQUINCOUNTY ORDINANCES,STATE LAWS,AND RULED AND <br /> REGULATIONS OF TME SAN JOAQUN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOI iDWING:'I CERTIFY THAT N THE PDRFOR./ANCE OF THE WOW FOR WHICH <br /> THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* CONTRACTOR'S HIRING OR OUR-CONTRACTNG SIGNATURE CERTIFIES <br /> THE FOLLOWING 'I CEMIFY THAT INTHE MMANCE OF THE WOR(F')RL WHICH THIS PERMIT 10 WDUED,I'MALL EMPLOY PERSONS SUBJECT TO WORKLILA 'S COMPEN{ATION LAWS OF <br /> CALFOH NIA.' T NT MUST CALL LPI{N ANC!PoR ALL 1E0U11m IN TION{AT I={{I by-il3l.COMPETE DM'MNO AT LOWER AREA PgVIDEO. GGG <br /> 869-1 X Itl.""'S DYa <br /> MOT PLAN IDI -SW.1%.ae _ <br /> 1. NAME F ETD OR ROADS NEAREST TO OR BOUNOING THE 4. LOCATION OF 14OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NOMN DNECTI EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AHO PROPOSED E.LOCATION OF WELLS WITHIN RAV4US OF ONE HUNDRED FIFTY FT. <br /> STRJCTVRES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> L <br /> .. .. ... <br /> .. ........... - .... ... <br /> �......:... :.. .....,...., PI'IR1T <br /> rt;'J k • <br /> ....i... ; c. ., ........................... ...._ <br /> ...-.. .. y. :.....�.....e...... . <br /> Q.A.N. ..9 1996 . . . . <br /> - I <br /> DEPARTMENT USE ONLY <br /> A-k.0—Aac. By �� NM <br /> I , <br /> Gre.n In.n.alon Br_ DER r2 9(o wmP Lr.y.ctlaD Br 11M. "� � v <br /> D�IlUGYiw,Frpaod.n P.y r �,� <br /> 6 Y <br /> co,nn,.,N: a <br /> cowl� -f CA,Sr <br /> ACCOUKTIMO ON r: RADE FACE <br /> PE C:1OG AMOUNT UTTED VMC RECEIVED NY DATE P41FMT/MIN INYOME <br /> EN� <br /> MID <br /> v fX�g <br />