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APPLICATION FOR WELLJPUMP iPERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION i <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <br /> (209)468-3420 <br /> AQ <br /> N•REF <br /> UIlQA9LE PERMIT EXPIRES 1 YEAR FROM DATE <br /> ISSUED <br /> I {CBmplets M irlpUest.l Ij f <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCFISED.THIS APPLICATION 10 MADE IN COMPLIANCE WITH SAN <br /> JOAOUFN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUTN COUNTY PuBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISM14. <br /> CITY <br /> 'C-/(°� PARCEL 81ZE m"s <br /> JOB ADDRE911DR APN/ - <br /> 1 OWNER'S NAME G. / e'T G�� , `� AODFIESS I _ PHONE . <br /> 1 AODRESS � Gc> S L;Cl PRiOffE.. 37 - z�15 <br /> CONTRACTOR 1-� <br /> SUB CONTRACTOR <br /> V i i <br /> TYPE OF nmLmp, C3ww WDLL ClREPLACEMENT WEu WTOF NG WEL>.. iii OTHER <br /> ❑ WSTAL ATHM ❑ WELL SYSTEM REPAIR ❑ CMSSCONNECT REPAIR1 ❑ VAPOR EXTRACTION WELL/ J <br /> ❑N.r.©R.o.M H.P. DEPTH PUMP SET____._,.. 1; FIRST WATER LEVEL O <br /> (TYPE OF PUMP! is <br /> ❑ OUT-0RSERVICE WELL ❑ GEOPHYSMAL WELL r ii ❑ son wmNo 9 <br /> ❑DESTRUCTION• <br /> INTENDED ULE' TYPE OF IO <br /> WELL CONSTRUCTION SPECIFICATIONS '3 A <br /> 0 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION � L`v OIA.OF COTOR CASIMM O <br /> D DOMESTIGPR IVATE ❑GRAVEL PACIUSIZE TYPE OF CASINGMTEEUPVC I} OIA.OF WELL CASINO L�� O <br /> ❑ FUBLIGMUNICIPAL ❑ORBVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ MRIGATIOFIIAG ❑OTHER GROW SEAL INSTALLED BY li GROUT BRAND NAME r V E <br /> ❑ MONITORING �.,j GROUT SEAL PRIMPED. ❑Y. ❑Ne �I 2CONCRETE PEDESTAL BY DRILLER ❑Y.. ❑N. s <br /> APPROX.DEPTH LOCKING CHESTER BOXIBTOVE PIPE S <br /> PROPOSED CONSTRUCTIONIOPOIA"METHOD: MUD ROTARY ASI ROTARY ATMER11 �CABLE OTHER <br /> j <br /> LI <br /> 1 I HEAERY CERTIFY THAT 1 HAVE PREP 9 APPLICATION AND THAT THE WOFK WLL BE DONE IN ACCORDANCE NMRTH SAN JOAQUIN COUHTV OROINANCES.STATE LAWS.ANO RULER AND k <br /> REOULATIONS OF THE SAN JOA HOME OWNER OR LICENSED AGENT'S STONATURE C11"FES THE FOLLOWIPXTt•I CERTIFY THAT AP THE pE1FO1KlMICE OF THE VVOii(1IOR WHICH <br /> THIS 19 ISSUED.1 SHALL T EMPLOY N9 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUF6FtwA.- CONTRACTOR'S WIND OR SUB-CONTRACTHIO SITNATURE CERTIFIES <br /> THE CERTIFY T T IN THE RMANCE OF THE WORK FOR WHICH TWO PERMIT 19 ISMIE'D.11lIALL EMPLOY PERSONS SU41£CT TO WOM MAWS COMPETNSATION LAWS OF <br /> CAU F ANT M T C 21 HOURS M ADVANCE FOR ALL REOUIRED mSPOCTTOIRP T 1205 /YJI22, COMPLETE ORAWMIO AT LOWER AREA PROVIDED. <br /> Slpned X l I.- Dad <br /> Lp <br /> PLOT PLAN R]r.w to 96060 Sal. 'to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNdNO THE PROPERTY. ij 1. LOCATION OF HOUSE SEWAGE 009POW SYSTEM OR PROPOSED 1 <br /> 2. OUTLINE OF THE PROPERTY.Or.-MM OIMENSIOW AND NORTH DIRECTION. - I EXPANSION OF SEWAGE dSFOsu SYSTEMS. ' <br /> 2. DIMENSIONED OWLINEB ANO LOCATION OF ALL EXMrMII AND PROPOSED I S. WCATION OF WELLS WITHIN RADRI9 OF ONE MINOWD FIFTY Fr. <br /> STRUCTURES,MCLUDMRG COVERED AREAS SUCH AS PATIOS,DraVEWAYS,AND WALKS. ON THE PROPERTY OR ADJORVNG PRDPERRY.' y <br /> r -- ... _ _. _ ... <br /> 1 ......:.. ....... ........ .. .....,.. _ ... ..... _ .. _ .. <br /> 1 " <br /> - <br /> -ILE <br /> ............ <br /> ................. <br /> ��' <br /> i . <br /> OEPARTMEPT USE ONLY - <br /> il L4 ZZ Arr <br /> AVPO"Il.n A"Wvd BY onto <br /> O.eu1 NNPo.tlen Br E... L1 'L6 Hfi. K ��' itene 11wp.etlan By -i1 � vole . .. <br /> �] On. <br /> ` Oe mpmlen Irwneatlen 9r - -- - <br /> Cenems.lr { <br /> ACCOUNtM ONLY". MDI FAC! I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECIUICASH REcEr4w 9Y DATE I; "'T1SERVICE REODUT NUMSBR INVOICE <br /> det <br /> 35'04el-00 -oo k04 4424, <br /> I Fub 4ealth Serv.-=nvito. 173 11;'97) JL <br />