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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOU�N COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> •`` ' 0.BOX 988.904 EAST WEBER AVENUE,STOCKTON.CA 95201388 <br /> C. <br /> {209)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRE] 1 YEAR FROM DATE ISSUED <br /> _\ ICampNta In TrlplicmW <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANMOR INSTALL THE WORK DESCRIBED-THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAOUN COUNTY DEVELOPMENT TRIS.CHAPTER B•1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRE881OR APN7 7- CITY PARCEL SIZE/APNf <br /> 5,69,0& <br /> OWNER'S NAME �j� AOD�RLEtiB C,, <br /> CONTRACTOR /moi/C/Yl l�lt��- S AS]ORESS l.+Z�L" [�� ��f / HE <br /> �/�(� l ' J per. /69 �J�/�PHjONE/_g �ta,� <br /> SUS CONTRACTOR �/i f 5,iFvAD071E88 �t/ ��IcX+�-a L1Cf(p�/1 C�G�IONE <br /> TYPE OF WELUPUMP, XNEW WELL ❑REPLACEMENT WELL ❑MONRORNG WELL♦ ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL s J <br /> -. ❑New❑P.O.], H.P._ _ DEPTH PUMP SET"FT- FIRST WATER LEVEL O <br /> ITVPE OF PUMP) <br /> ❑.OUT-OF-BERNCE WELL ❑GEOPHYSICAL WELL f ❑ 601L BOPoNG 8 <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS !' A <br /> ❑INDUSTRIAL 0OPEN BOTTOM DIA.OF WELL EXCAVATION / DIA.OF CONDUCTOR CASINO O <br /> ❑OOMEBTIC/RIIVATE IYf GRAVEL PACK1BtZE TYPE OF CA.M.-T111JPVC �i DIA.OF WELL CASINO d u D <br /> �}tI}j�y PUBLICRAUNK:IPAL '/�❑�--7I DRIVEN DEPTH OF GROUT SEAL �,/ / SPECIFICATION <br /> LJ 1RHIGATIONIAG LI OTHER GROUT SEAL INSTALLEDBy //'/ + GROW!MND NAME {. r___�r S �-� E <br /> ❑MONITORINO GROUT BEAL PIMPED.ODN- ❑Fb CONCRETE PEDESTAL BY DRILLER❑Y••)Aa S <br /> APPROX.DEPTH ` /0 LOCKING CHESTER BOX/STOVE PPE S <br /> PROPOSED CON{TR TWN(DRHINIG METHOD: MUO ROTARY_AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANI <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR W HtC', <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPERATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTINO SIGNATURE CERTIFIE <br /> THE FOLLOWING: ;I CERTI AT N THE PERFORMANCE OF THE WORK FOR VA4WH.THIS PERMIT 16 ISSUED,t SHALL-EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS 0 <br /> CALIFORNIA.- T MVf HOU1a IN ADVANC�REGIAR1'0 INSPECTN)NNI AT 11.1 400447..COMPLETE DRAWING AT LOWER AREA PROVW <br /> No-d X TIS• f/r«""G- iC/�T� OU <br /> Dein 3 �7 <br /> ROT PIAN M7 to Sc•I.1 Sul• r t,' P`I ri I <br /> 1.NAMES OF STREET ADB NEAREST TO OR BOUNDING THE PROPEHTY. -r' 4. LOCATION O H EF SELVAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PRO NO DiMENSI <br /> 7.DIMENSIONED OVTLNFS AND LOC ALL EXISTING AND PROPOSED "A LOCA N OF S HATH RAONS F ONE H NORED FI FT. <br /> STRUCTURES,INCLUDING COVERE ;AAE 5 SUCH AS PATIO BJ DRVEWA I - O KFY• -- <br /> Rlow L <br /> ,_.. . . a . .. <br /> x <br /> f <br /> T <br /> 3 a ., ... , ., R <br /> + b y La/ey <br /> .,B y <br /> bag 173, 1r'Si^3S <br /> 4.e <br /> 7 <br /> :. <br /> 7 <br /> - - �4 r' <br /> a(DA CUIIv 0G UN f <br /> DEPARTMENT ME ONLY PUBLIC HEALT S" VICES <br /> AI,Pll•NI•n Aa Pl. By ENVIRON pFr-d1, A.•• -21/ <br /> O/� s <br /> Gra.IrHINEUon By �iLf"{ t'rl D•tn , P-P Irnp-11-By <br /> D-­116m Imp-lnn By D•t �ItCCR A�l� <br /> �i,S! � .,�w+n,/yLtF•r+vrrr SIS !ii S< - �'f /I.-�'.r P - ,c.< �✓ � E%,S r.. Sc� rc�r�a, <br /> ACCOUNTING ONLY: AIDE FACE O50-t� � a /df�'s� <br /> rr <br /> PE COO" FEE INFO AMOUNT REMITTED HECK ASH RECEIVED BY DAT[ PETFOTtSERNCE RKOUEST NUMBER INVOICE <br /> 3 " 3 r,o0 4 . 8b <br /> 0 sc os-a -b ✓o. <br />