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APPLICATION FOR WELLIPUMP PERMIT <br /> AN JOAQUIN COUNTY PURLIC HEALTH SERYICFN <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 3% 304 EAST WEBER AVENUE; STOCKhOR CA 9=1,388 <br /> 120% 461-3420 <br /> go—s-101 ABLE FE MIT E]LPiNVE 1 YEAH Rffina QATf ISSIiEQ <br /> iIC "1019 Ia T►INNea1El <br /> A�M <br /> i - 06AT1DNW*W NY MADE TO THE SAN JOAOUIN COLINTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCAWD,TISa APPLNCATION 18 MADE IN COMPLIANCE WITI!SAF! <br /> JOAODSN COLIMY DEVELOPMENT TITLE.CHAPTER 9.1115.2 Am THE STANDARDS OF SAN JOAOUBN COUNTY IUKX IIEALTI!SERYICF.6.ENVIFb1NN1ENTAL HEALtH ONESION. <br /> r <br /> JOS ADORESMOII APNS CITI PAF CEL S12FJARU <br /> ` ♦ .7/ /f'rYr Ian■ <br /> DQE ADDREEa <br /> PNOHE 1409f 9v/ <br /> CONTRACTOR <br /> ADTInEaE/ uer44 Z2q pmw a <br /> EUECONTRACT AnrutEaE uc 1'NIOlal s7M� '_j,C7lS <br /> �❑{N�pl WELL ❑ REPI ACEMENT WELL ❑ MONITORMO MIE;L/ oTITEn <br /> � IFIbTALLATION ❑WELL SYST10,11 REPAIR ❑cnota.CONNECT REPAIR ❑ VAPOn EXTRACTION WELL I J <br /> (TYPE OF PUMPI <br /> ❑Naw❑RapaN H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL d <br /> - <br /> ❑ OUT-OF-SERVICE WELL ❑ OEOPIIYSICAL WELL S M--"O"SOROM s <br /> ❑EXIMORM geEITIIUGTIDN <br /> OHS N S IF'IC D S A <br /> ❑ME>1FSTRML ❑OPEN SATTOM DIA.Of WELL IiXCAVATIOH DIA.OF CONDUCTOR CASINO <br /> O <br /> ❑DOMESTK`JPMVAtE ❑GRAVEL PACKIWE TYPE OF CASINOISTEELNPVC DIA.OF WELL CASINO O <br /> ❑PIIRICAMUMCIPAL ❑Dnnom DEPTH OF OROUT SEAL SKCIFICATIO1I If <br /> ❑ TIONMG 13Owen OROVT SEAL INSTALLED BY 1294GROUT BRAND NAME L E <br /> MEIRTOIElM op 01`1040 REAL PUMPEO: ❑Yee QMC CONCRETE PEDESTAL BY DRILLM❑Yr as <br /> APPROR.DEFT" LOCKIIO CIIESTEn SOXATTOVE PIPE S <br /> FROFOOEO COIHTRIft"OHMM UNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1"VOW CERTIFY THAT I HAVE PREPARED Tits APRJCATION ANO THAT THE WORK VML SE DOME M ACCOROANCE WITH SAN JOAOUNN COUNTY ORDMANCES.STATE LAWS.AND IWUg AND <br /> PMKAVWM OF THE BMT JOAOUIM COUNTY. HOME OWNER On LNCEIMED AOENT'S SIGNATURE CERTIFIES THE FOLLOW a.'1 CERTIFY THAT M THE FEKORMAME OF THE WOW"M WHICH <br /> TNMIEIMEIT HIi8GUED.I.WIALL NOT EMPLOY PERSONS KniaCT TO WORRMAN'S COMPENSATION LAWS OF CALIFORIA&- CONTMCTOR'f HMMHO OA SUS-COMP.ACTIIRI BKMTUIM CEIITIFIE0 <br /> TIM fOtiOIMFIOt 'I CERTIFY THAT IN T!M PEI1FO10AANCE OF THE WOTK FOR WWCH THIS FERMI IS ISSUED.1 SHALL EMPLOY PERSONS SULIECT TO VMN MAWS COMPENSATION LAWS OF <br /> CALIFMSEA' TIM A/Ftl MUST GA11 2r1 MO ADVAMCI PMI ALL PROVOKED INOMMMS AT 12181 4004422,JCOMPLETE DMWOM At LOWER AREA PROVIDED. <br /> of K • ThM ! Data <br /> PLOT PLAN IDraw to Base!Selo •to <br /> 1. NAME OF 9111tET8 OR ROADS NEAREST TO OR SOUNDING TtIE PROPERTY. J. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> S. 91I10111 OF TOW PROPERTY.OIVENO DIMENSIONS AND N01T►N DIRECTION, EXPANSION OF SEWAGE IXW4WAL SYSTEMS. <br /> 2. OSIELTIMOIIM OUTLINES AND LOCATION OP ALL EXIS►UIO AND PROPOSED i. L.DCATION OF WELLS WITLiIN RAMS OF ONE HUNF7FIED FIFTY FN. <br /> 1TlElGTLIIlE;1fICL1/D1Iq COVERED AREAl111C11 AS PATKlS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINRKI PROPERTY. <br /> DEPARTMENT USE ONLY <br /> APplice0en Aaaopted ST . <br /> bate <br /> PUnP Y+Matllhe+ <br /> OaNttatMrt I�SaaOnr Sry Data <br /> Cawan�Me: <br /> AGGOIIFNTINO ONLY: AXW FACS <br /> lE COOEa M SIFO AMOUNT HIMMb CHSCKRICAS" RECBVED EY DAIR ►EI1110TISERVICE REOLISET HUNawk BNVOME <br /> 4 . Dzel�90 <br /> a <br /> Pub.Health Sarv.-Enyim.173(31M <br />