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APPLICATION FOR WELL/PUMP PEP" <br /> JOAQUIN COUNTY PUBLIC HEALTH, jVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 85202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRT! TEAR FR9M CASE 95UEU <br /> 1GmplrMl M 11fPRE11;l <br /> APFAICA1]ON IS TEAS BY MADE 70 TRE SAN JOAOUIN COUNTY FOR A PERMIT To CONS7IWCT AMIOR INSTALL TINE WORE DEECF eEO.T/SS AFPLICA710N IS MADE IN COMPLFANCE 1MTH SAN <br /> JOAOIRN cGUNTY PEVELOPMHfT TITLE.CHAFFER S•1115.3 MNV TINE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC ItE-AL111 BERVICEB.EMARONMENEAL WAL711 OIYISION. <br /> JOB AOURE6IGR ApN1 ALO tf 2/86 <br /> 2-212-N SY.. CITY jEl"A G4 PARCEL SIZEIAPNE /s.r <br /> OWfIFR"S f~/�..r R �/L Ic ANUREfE /)��ALL/...r� 4. Cr 4+1' L G RNJNErC+�' 1 <br /> COHIFACTOR Gam.: Pn AImIYii UlIVW rntz ucr AwNE aL�b})!3'- � <br /> WI COWRAcfOR rNIE A'�E App11Eq LIC/ ApNEO <br /> F�Lm1�P• ❑NEW WELL 0 MEYACEMENR VOU1 ❑MONO GRIM WFLL f 11 Gunn <br /> LL - <br /> [�INWAATION ❑WELL SYSTEM REPAIR ❑CIWBS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL <br /> ❑N—❑R.P.M1 H.P. PEP711 PUMP BEtFT. FIRST WAl ER LEVEL O <br /> P YPE OF PUMM LJ P-� VT �-E S <br /> DVT-OF-SERVICE WE1L Q GEOPI fYS1CAl WLLE / SOILBORING <br /> ❑CEO IIYICT ION. <br /> N ENDED UR TYPE OF W ONi7RIIC iOM SPECIE CA IONS A <br /> ❑INVUSTRIAI ❑�I OPEN BOTTOM MA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASOIo P <br /> 01)OI.fESIICA'RNATE MJ OMVFL PACKfE1ZE TYPE OF CASINOf6l EEMJPVC DIA.OF WELL CASINO D <br /> ❑IETELICmUmicwAL ❑UWVEN DEPTH OF GROW REAL n SFIECNICA1Wf1 R <br /> ❑WMAI00N/A0 ❑OTHER GROUT SEAL DRi ALLED�yBIlY ��I�.E 'G P" — GROW BRAND NAME E <br /> CI MONITORING /] / GROUT SEAL nMPEM d Yr (IN. CONCRETE PEDESTAL RY DIYLLEh❑Y.• ON. 5 <br /> APPROK.DE►IH CJ^+s<O 7�f-E� LOCKING CHESIER SOXIBIOVE PIPE <br /> PROF OFO CONSTRVCTICHIDRLLINQ METHOD:MUOIIOTARY AIR ROTATTT AUGER CAULS OIIIFIt 1fYLt� P,Ai 11 <br /> I HERCSY CERFIFY THAT I HAVE PREPAREO TINS AMMATION AND TIIAT TIE VVCW WILL BE DONE IN ACCOFIDANCE IMTH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> NEOUTATIONS OF TIIE SAN"AM"COUNTY,HOME OWNER OR LICEN*fO MEW'S S1GNAfURE CERTWES 7HE FOIEOWINO:'I CERTIFY%HAT IN THE PERFORMANCE OF TI1E WORE FOR WINCH <br /> TIpS F! 7FS ISSUED,I SHAIL NOT EMPLOY PERSONS SUBJECT TO WGPWMAN,a COMPENSATION LAWS GF CALIFPRMA,'CONTRACTOR'*NNTHO OR WB�CGWRACI IND SIGNATURE CERT IrKS <br /> TIN roll ~10: '1 CErawy 111At W 711E PEMO NCE GF EINE V/ FW FOR YRIICII TINS 1'EIIKNT i51SE11E6,1 SNALL EMPLOY PEIISONS SUBJECT 10 WORKMAN"B COMPENSATION LAWS OF <br /> CAHFO A.- TIC ANF MUST CA N 110 i N ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1 LM 441./1.'23..1 C/.OMPLEEIEE DMWING AT(OWER AREA IMMM <br /> M <br /> SIirW X TIN. / ! !a (`�--�' t,- _D•f• <br /> PLO I PEAR W.—I.S..I.I NW 't. <br /> 1.NAMES OT STIES R POAGs ttwtm 1008■ouNo a TUE Pno PENNY. 4.LOCATION OP HOUSE SEWAGE INSPOSAL SYSTEM OR PIIOT'OSED <br /> T.OUTLINE OF TIME PERTY.GIVRIO PIMEINIONS AND NORTH DIIIECTION. fXPANMI4 OF SEWAOE DISPOSAL SYS/EMS. <br /> S.O"IN—NEO OMLNNFi AMO LOCATION OF ALL ENJOYING AND PROPOSED D.LOCATION OF WEUS VMNIN RADIOS OF ONE HtI D XD FIFTY FI. <br /> 91RUCTURFE,SICLUDMO COVERED AREAS SUCH AS PATIOS,OWVEWAYS,AND WAtKE, ON 71E PROPERTY OR ADJOINING PROPERTY. <br /> . ? ., <br /> J....i. +....�.. <br /> a VIA <br /> pE}MIMENT USE ONLY <br /> AFPtlo.Non Amy1.i EY <br /> Qrwn M,.Prll•n ST D•l rL—p 1-11.A BY a C.D`n• <br /> c«„m.a.: '�;1' 7-✓y..-f .-a,/e X3'1 o LA-t �_Z-r�.� <br /> ACCOUNTINO ONLY; ANO; FACF <br /> rt CODES FEE INFO AAMOUVIT REMIXED ICASN MC13VIM SY DATE VEIMTRERVICE RTOUEST NISNSEI INVOICE <br /> 9 — �S/6S 7/ O `I <br /> Pub.lifallh SBEy.-):I1YNo.173(1/97) <br />