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` V APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION �l <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 f <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICBmpAN In TTbREEbI <br /> AMICAT ION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OB INSTALL THE WORK DESCRIBED.TIIIS APPLICATION IS MADE IN COMPLIANCE WHIN SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 81115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIMEIMENEAL HEALTH DIVISION. <br /> JOB AOORESSMR APNE LMS C[q •Xl• �j/NUw/�� I�i+/ CITY V /J PARCEL e1ZEJAPII�j(J��/ <br /> OWNER'S NAME Fi-T)�-A�F=�T /J /P.Di//H/� AODPESS a,�dj/L /�� L%� AgNEF ` �/ (� <br /> CONTRACTOR O/y'p� S-A' �iLE A0011EBSL10 /h /UCPIONE/p3i�✓7O/T <br /> SUB CONTRACTOR ADDRESS LIGE PHONE I <br /> TYPE OF WEUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORINO WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WE�LIL�SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J� <br /> ❑New❑RepNr N.P. DEPTH PIMP SET�_FT. FIRST WATER LEVEL <br /> PYP'OF PUMP) —/ <br /> ❑ OUFOF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BOOING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO A r <br /> XDOMESTICA'RIVATE ❑GRAVEL PACKIBIZE TYPE OF CASINGRITEEVPOO DIA.OF WELL CASINO O <br /> ❑ PIBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ( I� <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY BROIL BRAND NAME E G <br /> ❑ MONITORING ^^ff GROUT SEAL PUMPED: ❑Y. ❑Ne CONCRETE PEDESTAL BY DNILLER:❑Y.. [:IN. S A <br /> APPROX.DEPTH /�.fes �C Yc� LOCKING CHESTER ROXISTOVE PPE S <br /> PROPOSED CONETRUCTION/UFELUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS AITRJCATION ANO THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN AAOVIN COUNTY ORDINANCES.STATE LAWS,AND flUlEe AND <br /> OEORRATION9 OF THE SAN JOAQUIN CODITFY. HOME OW n OR LICENSED AGENT'S SIGNATURE CERTIFIES THE MUOWORQ:"I CETIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH5 <br /> THIS PERMEF IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONERACTOR'G HIRING OR SUOCOEFRACTINU SIGNATURE CERTIFIES 1 <br /> THE FOLLOWING: •I CETIFY THAT IN THE PERFORMANCE OF THE VAR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAHFORNIA.• TIIE P`IICAMT MWi C,J LL]�HOURII IN ADVANCE FOR ALL REQUIRED E <br /> � <br /> IN�SPECT�IONS AT(3081 ASS.MSS. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> GISA.d% Till. <br /> D.I. <br /> KOT PUN IOr..Y to Bartel 8aeb le <br /> r� <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOBAL SYSTEM OR PRREMSED <br /> 3. OUTLINE OF THE PROPERTY,GIVNIO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAQE DIGPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUELINEG AND LOCATION OF ALL EEISTINO AND pRDpOSEO S. LOCATION OF WELLS WITMN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WAU(e. ON THE PROPERTY OR ADJOINING EFIOPREY, <br /> kFeg <br /> : <br /> TMENT USE ONLY <br /> AppllaHbn AveWHM BY Arr ~ <br /> G,am In.pecllm BY D.H. IAmp Ip.P.anan ar OH.I�"' �9-�� <br /> Dabwllen L,F-tbn BY Deb <br /> o—Z9-4f <br /> ce�nmNn.: l�l'eFE 7`EC WC H 4lRUK <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CREC CASH RECEIVED nY DATE PEAM1OTISERVICE REQUEST NUMBER INVOICE <br /> SSUcm �x�_ �l0 9 La3z0 <br />