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L APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES \ % <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N.SAN JOAQUIN ST, STOCKTON,CA 96201.388 X5053 <br /> (209)468.3420 <br /> NON-REFUNDABLE PERMIT Elf%RES 1 YEAR FROM DATE ISSUED <br /> (C.mpl.t/1n TAp ato) <br /> AFRICATIOII la HERE BY WAVE TO THE SAN JOAQUIN COUNTY FOR A PERMrr TO CONSTRUCT ANDIOR INSTALL THE WORK DEOCFSBEO.THIS APPLICATION IS MADE IN CCMRJANCE W TH SAN <br /> JOAQUIN COUNTY DEVELOPMENT <br /> TTIITTLL�E,CHAPTER B 1 1 S.3 AND THE ST�A.N{/DARDS 05.SAN JOAQUIN COUNTY P C HEALTH SERVICES.ENVIRONMENTAL HEALTH DfVIGION. <br /> JOS ApD(lFgggR AINr_ l(/ VJFJ �J e��_/� {/(•/(Y{�)J1 CTI P NZE/AiTII <br /> OWNER'(NAME ii ADDRE 6b N' p///yl- / <br /> CONTRACTOR0a 1K ADORE" E , PHONE r sr4V <br /> &!@ CONTRACTOR <br /> Be ucE� neoNEr <br /> TYPE OF WFUJPUMP. WINEW',YELL ❑REPLACEMENT WELL ❑MONrTOI@N(3 WELL S ❑OTMR_ <br /> r}- /// / 36•.Q11' Y. <br /> Iye-ALLAT)0 ❑WELL SYSTEM REPAIR ❑CROS6-CONNECT REPAIR 13 VAPOR EMACTOON WELL r <br /> e)ff�/ , —❑R •I: H.P. DEPTH RUMP SET FT. FIRST WATE!t LEVEL <br /> (TYPE OF PUw O <br /> ❑OUT-0F-SERVICE WELL ❑GEOPHYSICAL WELL E ❑ SPIE BGwNG r <br /> e s <br /> ❑DEFMUCTION: <br /> PITINDED LUF Y •Rv 7SINGISTEELLPVC <br /> T10Ns 11 <br /> NDUeTRIAL OPEN BOTTOM ( A <br /> DIA.OF WEN pA Or CONOVCiOfl CASINO D❑ DOMESTIC/PMVATE ❑GMVEL PACILJ@L2E TYPE OF C+� VC OM.OF WELL CASINO 1T❑ UNIC I►AC ❑DRIVEN DEPTH OF GSPECWCATIOND <br /> NI.OILTIOWAG ❑OTHER GROUT SEABY GROUT BRAND NAME <br /> ❑MOMTORNO GROUT.IAYw Ne CONCRETE PEDESTAL @Y GRILLEN. $ <br /> APPIIOx.DOTH LACxJNO CHESTER boxiSTOVE RPE_ <br /> PROD/m CONSTIRICTIONRRgWNO METHOD: MUD RDTARY_ NR RIOTARY AUGERCABIF OTHER <br /> S <br /> I MEItESV CERTIFY THAT I HAVE PREPARED TMS APPLJCATION AND THAT THE WbIEL WILL SF PONE IN ACCORDANCE'AaTH SAN JOAQUIN COUNTY ORDINANCE/.STATE LAWA FAXES E@ AMD . <br /> REOJLATIONS OF THE SAH JOADUIN COUNTY,HOME OWNER OR LICENL'FD AGENT'S MONATURE CERTIFIES THE FOLLOWING;•I CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHICH <br /> YN <br /> TMS PERANT 1/ISSUED,I SMALL NOT <br /> NOT EMPLOY PERSONS BUBJECT TO Woft7AAN'S COMPENSATION LAWS OF CALFORNIA• CONTRACTOR'S MWNO OR 91111-CONTRACTING 91ON.10 CERTIFIES <br /> THE FOLLONO: 1 CERTIFY THAT W THE RMANCE OF THE NgfK FOIL NMx:H THIS PERMIT I/ISaUED,I/HALL EMPLOY PERSONS SUBJECT TO WORxMAN•S COMPINSATIOM LAWS OF <br /> CAJOIA• MUST CALL] URS N VANCf FOR ALL\SGUN®IN"TIONS AT f2O@I AM 2423. COMPLETE DMWNO AT <br /> IAVJEl1 ATEA PROVIDED. <br /> .'116 D—1 <br /> PLAT PLAN IDS 1.&. .I gW •10 <br /> T- NAME FS OR ROADS NEAAE@T TO OR BOUNOINO THE PRO �, LOCATION OF MOUE SEWAGE DISPOSAL SYSTEM Olt PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,DIVING DIMENSIONS AND NORTH E%PAN TION F SEWAGE DISPOSAL SySAL SYSTEM <br /> 7. DIMENNOMM 04JTLWES AND LOCATION OF AL1 EXISTING AND PROPOSED g.LOCATION OF WELLS WITHIN RAORJS r ONE NUNDI<m FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIO@,DIVVEWAYO,AND WALJLg. ON THE ONO F WE LS ITHI NRAING IW OF ON <br /> :....•............:..... ............: <br /> .:....i .......i <br /> _... .. .. <br /> :. .... .. <br /> EIN X. <br /> ... <br /> DOARTMEJR L—Ma OI0.Y <br /> A''E'�___f– , <br /> G—In. ti—Br /2 <br /> D.I. 96 w,.:P v+.P«:1.,,er <br /> Dn <br /> ACCOIINTr:O O Y: NDE FACS <br /> K COLO/ AMOUNT RE/i TT® [C KASH RSCBVED lY OAT[ Pv.AITI{OtVN.E REOUSST NLEADER INVOICE <br /> -�- z S oa53a� <br /> Da S3 a Q <br /> OD� — <br />