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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> RO, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (2091469-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (ComPN(o In Triplioalal <br /> APPLICATION 18 I{ERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TIRS APPLICATION IS MADE IN COMPLIANCE WITII SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1 1 15.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC IIEALTII SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODRESS/OR A�1PN/ _4C)o F f 1 .� CIT-11 I PARCEL 91ZE/APN/ <br /> OWNER'S NAME_C//'LktL SU �pt]'ti(�a,i., (J� To.Nr�(b' MJ ADDRESS 5 sr -1a�Ir <br /> T= •_� 77 '.I PHONE It C��1, � <br /> CONTRACTOR (fyV� ��^�^� (� AODRE89 Z..76S r'V LS(,L1Plrn S yl�UCl (� PHONEI may_ �.-Q�(i'7� <br /> RUB CONTRACTOR �T-�"c <br /> ADDRESS UC/ PHONE/ <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 9 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> J <br /> New❑Repelr H.P. DEPTH . FI <br /> PUMP SET FT. WATER LEVEL <br /> (TYPE OF PUMP) / O <br /> ❑ <br /> ❑DESTRUCTION: OUT-Or SERVICE WELL ❑ GEOPHYSICAL WELL I U 6OIL SOWING -3 <br /> B <br /> INTENDED USE TYPE OF WELL CONSTRUC7IOrR SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONA <br /> C1 GIA.OF CONDUCTOR CASINO D <br /> DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC <br /> DIA.OF WELL CASING O <br /> 13❑ PVBLIC/MUNICIPAL 11 DRIVENDEPTH OF GROUT SEAL SPECIFICATION <br /> A <br /> IRRIGATIONG ❑OTHER GROUT SEAL INSTALLED BY <br /> GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yee ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No 5 <br /> APPROX.DEPTH (�j� �e�� <br /> LOCKING CHESTER BOX/9i O',E%PF <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTAM ---AIR ROTARY AUGER CABLP OTHER L� y V� <br /> I HEREBY CERTIFY THAT I I{AVE PREPARED THIS APPUCATION AND TITAT T14E WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> REGULATIONS OF T14E SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'8 SIGNATURE CERTIFIES THE FOLLOWING:'t CERTIFY THAT IN THE PERFORMANCE OF TIRE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMA O THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP"SATION LAWS OF <br /> o <br /> CALIFORNIA.' THE A CANT MUST CALL 24 IN ANCE FOR ALL REOUIR NSPBCTIONS AT 1205)46111-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 910ned X s,1/ <br /> Tltle �� /9fl <br /> ow. /1 <br /> PLOT PIAN IDrew to Seelel Salve to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF 14OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.OIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 0. DIMENSIONED OUTLINES AND LOCATION OF ALL EX19TING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ._.... .... ... ....:...... .... :._..... _ ..... ... r. _ ... <br /> Applleetlon Accepted By /ellm­a-q - Dete .Are. ClI `^U) <br /> Grout Impectbrt By Pt—p Inroxtlen By Ueb <br /> Oeetnretlerr Imnxtlor.By / not. <br /> ACCOUNTING ONLY: AID( FAC/ <br /> PE CODES FEE INFO AMOUNT RETMTTE'D CIIEC # ASIR RECEIVED Sy DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> Pub.Health Serv.-Enviro. 173(3/96) <br />