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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES WELL <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 Z-(,- S - ll h 0',5 7 <br /> 11011-REFUNDABLE PERMIT EXPIRES I YEAR FROM UATE ISSUED / / <br /> (CBmp1REE In Tri,DcRT*I 'y <br /> AM ICATION Hi NFRE BY MADE TO THE*ANPOACM COUNTY FOR A PERMIN <br /> IT TO CONSTRUCT ANDton STALL THE WOw(DESCRIBED.TIII6 APPLICATION is MADE IN COEIPLIANCE Wrr11 SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111 6.9 AND THE STANDARDS OF RAN JOADIAH COUNTTYY[PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIADION, <br /> JOB ADORERSIOR APNF yy Z - Illy \rrCtl.- PARCEL RIZEJARI► C <br /> OWNFR'S NAME /C C_iJ T TL ADDRESS �bC}�l' (S/t,{.[�.'�l RN1NE J o aS " <br /> COMMC100. yy� jl ADDRESS T6 L� ;,x 1 rjC•-y UC/ NE 191 b-J T-i-k <br /> A�S 11 <br /> 9Ve CONTRACTORAI%H+f eB G -Gfi I ,HE F <br /> TYPE OF WELL/PUMP, IJ NEW WELL ❑RLPIACEMENT WELL ❑ MONITORING WELL I T1--11 OTHER <br /> ❑INSTALLATION [I WELL SYSTEM REPAIR ❑CROSS0 <br /> .CDNINICT REPAIR VAPOR EXTRACTION WELL/ J <br /> ❑N_13 11P.A M.P. DEPT"FVMP guy FT_ FIRST WATER LEVEL O <br /> U YPE OF PUMP) ��e---/// 2 ,���yyy,,, "� <br /> ❑Ol/i-OF-SERVICE WELL Lbj OEO[11V SIC RL WELL J 'tel �jl -11 SORNO _ g <br /> ❑DFSTRUCTNIN; \ <br /> INTENDED USE TYPE OF W CON17TIlKTION PECIFICA7bNl A <br /> ❑INnUSrRTAt ❑OPEN BOTTOM DIA.Or WELL EXCAVATION DIA.OF CONVCTORCARINO O <br /> ❑o mi9TICATJVAIE ❑GRAVEL PACR/SrZE TYPE OF CA91NCIMTEEL/PVC _ OW OF WFI.L VA.— p <br /> ❑F'LRLICBAIRMWAI. ❑DNIVFN DEPTH OF OROUT SEAL RI'ECGICATION <br /> ❑M"GATION/A0 ❑OTHER GROUT SM INSTAUED SY GROUT BRAND NAME <br /> ❑EIownTowNo GROUT SEAL PUMIND:❑Y« [IN. CONCREI E PEDESTAL BY CfwLFR:❑v.. ❑N. S <br /> APPROX-DEPTH LOCKRIG CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONMOLUNO METHOOI MUD ROTARY AIR ROTARY AtWR YN` CABLE Or/PER <br /> I"F-WHY CERTIFY THAT I I?AVE PREPARED THIS APPLICATION AND THAT THE WOHL WILL BE DONE R ACCORnANCE WITH SAN JOAI t N COUNTY ORDINANCES,STATE LAWS.AND RULED AND <br /> 'WOUI ATIONS OF THE BAN JOAW"COUNTY, HOME OWNER OR LICENSED AOEM'B SIGNATURE CERFMWI <br /> IES THE FOLLONO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW fOn WIIICII <br /> r HIB PERMIT 19 IRRUEO,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'R COMPENRATR/N LAWS OF CALIFORNIA_'CO TKACTOR'R/HRING OR BUB.CONTRACTING SIGNATURE CERTIFIED <br /> TME FOLLOWINGS '1 CERTIFY THAT IN THE PFRFOONIANCE Or THE WOEK FOR NnncH THIS PERMS ID IRSVED,1 SHALL EMROY PEReON9 SUBJECT TO WORKMAN'S COMM NIATION LAWS OF <br /> CAUrORMA•• TRW APPLICA 7T MUST CALL 24 MUHR IN ADVANCE FOR ALL 1ROUNIED INiriCTlON/AT 12"14"3.12, COMPLETE DRAWING AT LOWER AREA IROVIVEO. <br /> PLOT PUN IN—to-1 S.dm M <br /> 1, NAMES OF STRS OR RDAOS NEAREST TO OR BOUNDING TI4f PROPERTY, J. LOCATION OF HOUSE BEWAOE O1 IPOSAL SYSTFM On PROPOSED <br /> 2. dJTLINE OF EET <br /> THE PROP'F.F TY,(WANG DBAEN6b NS AND NORTH DSRFCTION- EXPANMON Of SEWAGE DISPOSAL SYSTEMS. <br /> 3. DWENSIOI/ED OVTLNFB AND LOCATION DF ALL EATMTRO AND PROPOSED R. LOCATO OF WFLLD WTTLRN RADIUS OF ONE HU fl]bMD rRFTY FT, <br /> RTRU>CTLREB,INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK B, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> PAY <br /> MEN f <br /> hh ffJJ P' <br /> I i <br /> :.. . <br /> 'SOU 1 3:2000 <br /> ?DBI,C <br /> ` FNUIRCPP.9i41TS, ' r '•rFf'tLr�Wlq'.; <br /> ENT URE ONLY 7 (r <br /> AJrIIaERIm A.—d ST.. <br /> G.o�t MPmlla.r <br /> By— <br /> Ll mt. � -/_gn:9Q <br /> Llvvn v, �1 v L )! T�bits4.Ai" M1(ek <br /> 0-� 'L-ko` <br /> ACCOUNTRO ONLY, A_ FACT <br /> rE CODER FEEINFO AMOUNT RFY.I111to PP6�� <br /> ■H RECEIVED BY DATE ►gNWITISE/MCE REOVEAT NtI IR9t 1pf"ME <br /> 3 I ( G' — iLA 13 op <br /> D <br /> Pub.H6B11h Sm.-Enviro,173(1197) �-'T � �� ci <br /> 6w <br />