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PAYMENT <br /> RECEIVED <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES SEP 2 0 2000 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> (209) 468-3420 ENVIRONMENTAL HEALTH DIVISION <br /> 1114REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Cempwte IB TrlpRents) _5-� <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.TI11S APPLICATION IB MADE IN COMPLIANCE VMH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1 116.3 AND T14E STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> i&D <br /> JOB AODRE89/OR PN/ szgCfTY A, �, n PARCEL <br /> 91ZEJAPNI� ��J'�l —/J7 <br /> OWNER'S NAME NESS ?�/ /�/ +�'J /^ JG�r PHONE ka _� L 44 <br /> CONTRACTOR AOORE88���� J-'I�-1b IJCPHONE <br /> SUB CONTRACTOR ADDRESS UCI PHONE F <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ ONTORIN43 WELL f 11OTHFR <br /> w ❑ INSTALLATION 11 WELL SYSTEM REPAIR CRb88-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ <br /> / u-� ❑New❑s..1' H.P. E PUMP SET FT. FIRST WATER LEVEL p <br /> (TYPE OF PUMPI <br /> ❑ OUT-OF-SERVICE WE P OEOPHYMCAL WELL I ❑ SOIL 90RINO S <br /> INTENDED USE TYPE OF WELL CONST UC710N SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTICIP4IVATE ❑GRAVER PACK/SIZE TYPE OF CASINO/STEEUrVC DIA.OF WELL CASINO O <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION S <br /> ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT BEAT PUMPED: ❑Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑Yse [IN* S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S <br /> PROPOSED CONS TAUCTIO N/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY TITAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'9 BIONATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA.' CONTRACTOR'S AIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T1418 PERMIT 18 MOVED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' T PPU MUS LL 24 HOURS IN ADVANCE FOR ALL REOUM`m` INNSPW/7q NS AT("41 401,f422. COMPLETE DRAWING AT LOWER AREA VID D. <br /> B*wd X Title 1j 0.1, D <br /> PLOT PLAN(Draw to Sostel Seel. to <br /> 1. NAMES OF 9TRF.FT8 OR ROADS NEAREST TO OR SOUNDING THE PROPfRTY. 4. LOCATION OF HOUSE SEWAGE DI9PO9AL SYSTEM OR RWPOBED <br /> 2. OUTLINE OF THE PROPERTY,OrVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE D49POM SYSTEMS. <br /> 3. DIMENBIONEO OVTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RAORUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIO8,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ... _ .... <br /> �D Q <br /> 3?S' <br /> _ <br /> E7iT USE ONLY /� <br /> Appllemlen Aeeooled By v V L�✓ , V_ I Date / A,--� D <br /> .------Dole t n --Dolor <br /> bra%Ly �� �� 2 <br /> c.c:.•r.•-•.,.n«.,a„_^__ � <br /> r <br /> Unelnrctlen I—pt;on By r l•iU,up, "3;'7 <br /> ACCOUNTING ONLY: AID/ FAC/ L <br /> PE CODES FEE INFO AMOUNT REMITTED CFIECKI ASN RECEIVED BY DATE PFMIT/SERVICE REQUEST NUMBER INVOICE <br /> USS u ._ _3 ,IL v <br /> 3� <br />