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APPLICATION FOR VVELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O.BOX 388,304 EAST WEBER AVENUE, STOCKTON,CA 95201588 <br /> (209)4883420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (C&ntpl&t&IS TTIpDut&) <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAWN COUN`Y FOR A PERMrT TO CONSTRUCT ANOMM INSTALL THE WORK DESCWREM THIS APPLCATION 18 MADE M COMPIJANCE WRTH BAN <br /> JOAOINN COUNTY DEVELOPMENT TITLEQCHAPTER <br /> \9-1115.3 AND TTTH,E(�STANDAIOB OF BAN JOACUIN COUNTY PUILLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> Job ADDRE6aroaCAPNa��rj` _]. N W L\ ` -\ c^{m{\R O ECS 1`l..'Cb PAPxCL MMAMO (� (� <br /> OWNER'S NAME 1 'PkT'X 1�`�T C���� ADORE.- I-y.l`]�Y �a]�Otp�' ^ c\ PHONE/� ],- <br /> CONTRACTOR L\N\U�'c`S A� U.'(^�\� ADDRESS <br /> BUB CONTRACTOR ADORERS LCI PHONE <br /> TYPE OF WELLRUMP: ❑NEW WELL ❑ REPLACEMENT WELL ❑ MOWT(RfNG WELL I ❑OTHER <br /> 111 INSTALLATION ❑WELL SYSTEM REPAIR ❑CRO88LONNECCTO�REPAIR ❑VAPOR EXTRACTION WE ILLL 0 J <br /> yL Nin❑ReP.ir H.P.�� DEPTH PUMPBETN.JL/'FT. FIRST WATER IFVEL LoUL v O <br /> (TYPE OF PUMP) / <br /> ❑ OUT-OF-SERVICE WELL Cl awpi YBLCAL WELL I ❑ BOIL BORING g <br /> ❑DESTRUCTION: . <br /> 9.7. <br /> TYPE OF W!LL 11CTI0N&PECIFICATTON& A <br /> OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASMKi 0 <br /> TICN.ATE0 GRAVEL PACK1RME TYPE OF CASING/BTEETJPVC CL-2 DIA.OF WELL CASINO <br /> 0 <br /> ❑PUBUCMUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION AJ <br /> ❑OBLIGATION/AG ❑OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME EJ <br /> ❑MONITOMIG `� t GROUT SEAL PUMPED:❑Yr ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yee CIN. St� <br /> APPROX.DEPTH J LOCKING CHESTER BOXISTOVE PHIL gv 1 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGEfl CABLE OTHER <br /> I HE-EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH GAN JOAOUM COUNTY ORDHANCEB,STATE LAWS,AND RULES A#T <br /> REGLAATONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PFAFORMANCE OF THE WORK FOR WHIG <br /> THIS PERNUT IR ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COIMPOISATION LAWS OF CALIFORNIA.- CONTRACTOR'S HOUND 09 SUBCONTRACTING SIGNATURE CERIN <br /> THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE Of THE WOW FOR WHICH THIS PERART 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM►M&ATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL N HOURS IN <br /> ADVANCE FOR ALL OW ►BCTONS AT r It`Gl 4(p.N1J. COMPLETE DRAWING AT LOWER AREA PROVrDEO.0 4 ,1O <br /> Bland X � lJ o Title �1 <br /> PLOT PLAN IDI le Spelel S"s 'tP <br /> 1. NAMES OF BTPEETB OR LOADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GMNO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> ].DIMENSIONED OURMFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS MTH&N RADROB OF ONE HUNDRED FIETY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ......... 2 .:.. <br /> a 1 <br /> : c/l.°3 J!U <br /> ..._ AAAA <br /> SES <br /> o Lc <br /> \A <br /> PAYMENT <br /> MA'R.1 9 1996 <br /> SAN,iOAGL Iry c vL <br /> PUBLIC HEALTH atP,'JICE <br /> LNV!RGNMENTALJ EriLTn i <br /> ty <br /> o� , <br /> ... : . \�.. :......:.... .� �...... .. ....:�... AAAA.. i <br /> DEPARTMENT USE ONLY Cj 4 L <br /> Applle It AmMted BY p/DIt l r �J Ar,y 7 <br /> Grevf Inpectbn By Dete P—rnl><tbn BY <br /> OstNctbn Rrwp—i—BY Du• <br /> Cemmint. . <br /> ACCOUNTING ONLY: MIDI FACT <br /> PE COD" AMOUNT REMITTED HEC ICASH RECEIVED BY DATE PE RMtTlSt RNCE REQUEST NUW86R INVOICE <br /> 3 O liI <br />