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1 <br /> APPLICATION FOR WELLMUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> WIDIFREFUIIOAILE PERMIT EXPIRES I YEAR FROM DATE 133010 <br /> "Iota III Tr4RMa19) <br /> APPLICATION 19 HERE BY MADE TO THE NAN JOAOUIN COUNTY FOR A PETMIFf TO CONSTRUCT ANOOR IH9TALL THE WORK DESCRIBED.TIDE A17LICATION IE MADE IN COMPLIANCE VATH SAN <br /> JOAOUIN COUP"DEVELOPMENT TITLE.CHAPTER 9-1116.3 AND JTHE STANOAFOS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVNgN.1ENTAL HEALTH DMDON. <br /> !OB AOORESIVOR APNV //O 7 J f/f� CITY S-/rcac Kron! PARCEL 9REJAPNE !'1 9 <br /> OwNEII'I NAME V A i4Nn/REQ ADOIESt SO p�lU A—jg/NEF�/ <br /> CONTRACTOR ®LEI If 4— ADDRESS 'l-- C/ PF]NE/ <br /> SUS CONTRACTOR ADOMM LICE PNOEE <br /> TYPE Of wELLRURT, ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL E ❑OTIIEH <br /> ❑NSTCCTA-LLATION ❑WELL SYSTEM REPAIR ❑CROSMd11RCT REPAIR ❑VAPOR EXTRACTION WELLF J <br /> ❑N...LJ RMW P. DEPTH PU1.1P IE/ R. FIRST WATER LEVEL O <br /> (TYPE of PUMP) <br /> -0RSERVICE WELL ❑OEOPPY*ICAL WELL E ❑ am BORING 9 <br /> ❑OESTRUICTION: <br /> INTENDER USE CONSTRUCTION PECIFICATIONB A <br /> ❑RIOVSTRIAL ❑OPEN BOTTOM DIA,Of WELL EXCAVATION bA.OF CONDUCTOR CARM 0 <br /> ❑DOWIITIC/ ATE ❑GRAVEL FACKIBOE TYPE OF CASNGNTER PVC DIA,OF WELL CASING O <br /> ❑PVIEICMYUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECNICATWN A <br /> ❑WJ"ATIONIAO ❑OTHER GROUT SEAL INSTALLED BY OFIO TT NMMD NAME E <br /> ❑MOMTONNG OROVT SEAL PUMPED:❑Yr ❑N. CONCRETEP[MIFTALWOWLLER❑Y.. ON. 3 <br /> APPROX.TIEPIN LOC%ING CHESTER BOX/9TOVE WE 6 <br /> PROPONm CONSTNUCTIONARILLWO METHOD: MUO VOTARY AIR ROTARY AVOER CABLE OTHER <br /> I HE4HY CERTIFY THAT I HAVE PEPAREO THIS APPLICATION AND THAT TRE WORK MAL OF.DONE N ACCORDANCE WITH NAN JOAGUN COUNTY ORDINANCES,RATE LAWS.AND RULES AND <br /> REGULATION*OF THE BAR JOAQUIN COUNTY.HOME OWNER 09 LICENSED AGENT'N SIGNATURE CERTIFIES THE FOLLOVVM:'I CERTIFY THAT N THE PERFORAANCE OF THE WW <br /> WORK FOR HICH <br /> M MT <br /> THMRIt HMD•1 SHALL NOT EMPLOY PERtONS SUBJECT 10 WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTORS HIRING OR*UBCONTRACTNG VOWATURE CE/1TUEt <br /> THE POLLOWR�0—RTIFI'THAT NTR{E PERFORMANCE THE WOW FOR WNICH TIM PERMIT 19 ISSUED,I MALL EMPLOY PERSON IUSACT TO WOMW W'S CO&IMSATION LAWS OF <br /> CALPrOP"A." eANT MVBT/CJ'��/`�'tI 1IOW AVCS FOR ALL REaUIRm IRtFSCTIONS AT L10/1 ISI-TIES.COMPLETE DRAMNO AT LOWEL NEA PROVIDED. <br /> @*.I%T �L� f TIB. Oe. 0iG <br /> 1 ROT RAN IO.S.,'le So l MW 'N , ,1 <br /> 1.NAMES OF STREETS OR ROADS!RAREST TO OR NOINOIA THE PROPERTY. M. LOCATION OF HOUR WWAGE DISPOSAL SYSTEM OR PROPOSED <br /> OK �I <br /> 1.OUTLINE OF THE PROPERTY.OMM ONNONS ANO NORTH DIRECTION. EXPANSION OF 9EWAGE pBPOM 9YSTEM*. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELL WRA <br /> ELI ION IRHI OF ONE HUNDRED FIFTY FT. <br /> N <br /> STRUCTU"m CLUOINO COVERED AREAB SUCH M PATIOS,DRIVEWAYS,ANO WALKS. ON TE PROPERTY OR ADMNFEO PROPERTY. <br /> . <br /> i <br /> PAY <br /> ' I <br /> :. : . . . •°. : 18.E -� <br /> ... <br /> F:C <br /> D9 TMRI17 USS."Ly (� �7/ , <br /> AtSNMNn A.~d a "^L 0.N sil LXJ ill- <br /> a— <br /> - <br /> a—I--o n lh 0.19 PA I—Gen BY O.I. <br /> p�l,tttl.n I.A.P.e—BY Ow. <br /> a b <br /> ACCstaMTINO ONLY: A10/ FACT <br /> R COON FEE INFO AMOUNT REMTTED C RCKERC N KECEP/Sb*Y bATf P/ASHSO.VICE REOMIBT NUNABFR INVOICE <br /> 1 o��ra <br /> \I Pub Health S9rv.-ERviro.173(1197) <br />