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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> `F. <br /> �� O, BOX 988,304 EAST WEBER AVENUE,STOCMN,CA 95201388 <br /> '� (209)461-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES }YEAR FROM DATE 13SUED <br /> (Complete IN TripketDI <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DMAJREO.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> ..Jr JOAQUIN COUNPY OVALOPMENT TITLE,CHAPTER 8.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DrnmN. <br /> JOB ADDRESSOR APN/ -/7 C/ITY PARCEL SIZFJAPN/ <br /> OWNER'S NAME5A7 ADD�IyIE-68 <br /> CONTRACTOR RbDRES�G-/ JKJ L. �O P�/ <br /> SUB CONTRACTOR //�/V`� � �lL-JF-G-.//F/� ADOREBB LJC/G/QC-s ,Low <br /> TYPE OF WELLIRIMP: XNEW WELL ❑REPLACEMENT WELL ❑MONRORINO WELL/ ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS CONNECT REPAW ❑VAPOR EXTRACTION WELL/ J <br /> ❑Nov❑R.Pi H.P. OFPTH PUMP SET_/FFT. FIRST WATER LEVEL O <br /> OYPE OF PUMP( <br /> ❑,OUT-OF-SERVICE WELL ❑GEOFFlYmCAL WELLI ❑ SOK BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS If A <br /> ❑INDUSTRIAL W.--L <br /> OPEN BOTTOM DIA.OF WELL EXCAVATION � DIA.OF CONDUCTOR CASINO O <br /> W <br /> ❑DOMESTICIMVATE OMVEL PACKISIZE TYPE OF CASINGISTEELIPVC /C�� OUl OF WELL CASING �( D <br /> R1BUCIMUNICIPAL /T❑F-•LI DRIVEN DEPTH OF GROUT SEAL py,T/'Q��-- SPECIFICAMN {mac-- �� R <br /> ❑IRRIOATIONIAG 1--J OTHER GROUT SEAL INSTALLEDE-BY //'!/951 lI> GROUT BRAND NAME <br /> ❑MONITORING GROVT SEAL PUMPED:w_ ❑Ne CONCPErE PEDESTAL BY DRILLER:❑Yr 5 <br /> IO <br /> APPX.DEPTH ! /0 ' � LOCKING CHEWER SOX/BTOVE PIPE 5 <br /> PROPOSED CONDTII TIOKMMLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WOR.WILL BE DONE M ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REOVLATIONS 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 WHICH <br /> IS <br /> THPERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOWS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FO U. 'I CERTIFY HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,L IIHALL�EMPLOY PERSONS SUBJECT TOWORMI AN'S COMPElNAMN LAWS OF <br /> CAUFORMA.' MUS HOURS M ADVANCE POR ALL RIGUIRED INSP —NS AT 12051 4401-N28.COMPLETE DRAWING AT LOWER AREA PROVID D. <br /> Two �lcG�7.Pv— 3 A7 <br /> MOT MN Mr.w 1.6.M.1 Sul. 'to_• /10UI /f'4f <br /> I. NAMES OF STTIEET ADS NEAREST TO OR BOUNDING THE PROPERTY. '^-' 4. LOCATION O Q SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> Z.OUTLINE OF THE PRO NO DIMEN610 � <br /> O.OIMENSIOF 0 0UTLINF.6 AND LOC 1 Of ALL EXISTING AND PRDPOSEO i�7 LOCA EDN OF LL8 WITH RADIUS F ONE H NORED F FT. <br /> STRUCTURES,INCLUDING COVEPE 8 SUCH A PPAiTMS:DRIVEWA y1N/�` _ON DP Ow PR PITY. - - <br /> t <br /> • <br /> �j ._. ' <br /> y <br /> ge <br /> -33 /6 Lr <br /> 24 <br /> P <br /> aim i9 Vhsr 3S - 7' <br /> .! J✓,6.2, 1 <br /> ..... .... ...... T. <br /> PE <br /> l//. w . . ....... . ... <br /> y. .. <br /> JAN JOAOU(NCGUNrY <br /> DEPARTMENT USE ONLY PUBLIC HEAL T SFV1C <br /> AppF..-A..-Id 0, ENVIRON E' A­ a2/1 <br /> CmtA Irnp«Lbn er OHe -z/�-�7 FPvnp rn.P«non`my DAu� !o <br /> 197 <br /> Drtructbn Irvp«tan BY � /1 OM w/I,C��w�� <br /> Et�° <br /> cpmm..H: <br /> 4f <br /> JJ✓S� � f'�ww,/ILstJ wijT S/,ri v 5! — �'S ��ri ,.< Cc� 8� n.i E XIf �r S�'frc//R`, <br /> Cor.{tecfee_s��h//eY'nt.w.. <br /> ACCOUNTIHO ONLY: AID/ FAC( Q a...c-o.�^�5 >TP A IO•o% <br /> rC Aae­-.41cle GN reit <br /> PE CODED FEE INFO AMOUNT REMITTED FEC CMH RECETVEO SY DATE PERNSTMERVICE REOUEDT NUMBER rr INVOICE <br /> 3 3 00 8 M C <br /> �380 SC&S-0 (o b <br /> ��z <br />