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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAl2UIN ST, STOCKTON, CA 95201.388 <br /> (209) 488-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUES <br /> IGBmPItb in Triplienttl <br /> APPIUCATION IS HERE BY MADE TO THE SAN J04WN COUNTY FDR A PERMfT TO CONSTRUCT AND/OR INSTALL THE MW DESCRIBED.THIS APBICATION IS MADE IN COMPLIANCE WTI SM <br /> JOAQUIN COUNTYOEVELD�P}M�E7M TRIS CHAPTER 9-11115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUSUCLHEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORESSIO/R/,q,P INR IL — O�/O♦�^�-1 /- CITY <br /> ..IT n�Tfl4, l PARCELS APNI <br /> OWNER'S NANO YUy lrp ` L�'s/.�l Rai.CIL (o ADDRESS G."�I 1541f I 14-xp/11 II /� GGPHONEI TT <br /> CONTRACTOR T0. VG/i GAO/g, MODREs5)471? wl/J[S jJIUQ UC'(0(_ PHoNEI SIO - OV <br /> SUB coNrRAcroR'��o �' �•��n in Iln.--� 2 �rt/ AooRFss7$'2,-yS�� ucIS12ZL-6 RHONE�$(Z <br /> TYPE OF WELJ%IMP 0 NEW WELL ❑ REPLACEMENT W2LL ❑ MONITORING WELL F I)\(ID_q Cl OTHER <br /> EL INSTALLATbN ❑ W SYSTEM REPAIR ❑ cnoss{ONNECT REPAIR ❑ VAPOR ExTRAR10N WELL I J <br /> ❑Nw ❑RSNI H.P. g_ DEPTH RUMP SET_FT. FIRST WATER Lk VEL O 1 v` <br /> TYPE OF PIUMPI _ Z\ <br /> ❑ OIITdFSERVICE WELL ❑ GEORIVBICAL WEIl I ❑ 601E BORING g <br /> ❑OESTRLUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION f/ CIA.OF CONOUCTORCASING fW+J D <br /> ❑ DOMESTICIPPIVATE ❑GRAVEL PM:KFSRF TYPEOFCASING/STEEUPJC pvc DIA.OF WELL CASING Il D y� <br /> ❑ PUBUCIMVNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL - SPECIFICATION O. Z' If I1p , <br /> ❑ IRRIGATIONIAG ❑OTHER GBOUT SEAL INSTALLED BY D'. GROUT BRAND NAME It7 E <br /> lz MONITORING /J P� GROUT GEAL BUMPED: ❑Y- 151 NP CONCRETE PEDESTAL BY DRUFR: Y- ❑N. s <br /> A Ox.DEPTH Y J .rTa LOCKING CHESTER SOMITOVE RPE 5 <br /> MOMSED CONSTRUCTIONIDIOWNO METHOD: MUD ROTARY MR ROTARY AUGER—CAEU OTHER 1 <br /> I HEREBY CERTIFY THAT 1 HAVE BIEPARM THIS APP4CATn1N AND THAT THE MW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND �) <br /> REGULATIONS OF THE SMI JOAQUIN COUNTY. HOME OWNER OR 110ENSED AGENT'S SIGNATURE CERTIFIES THE FOLIDWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IS ISSUED.I SHML NOT EMB.OY PERSONS SUBJECT TO WORnAAN1'S COMPENSATION UW60F CALIFORNIA,' COMMLTOWS HIRING OR SUSLONTMCTINGSIGNATURE CERTIFIES <br /> THE TOLL Im I CERTIFY THAT IN/I HE PERFORMANCE OF THE WOR(FOR"ICH THIS PERMLL IT I6 ISSUED.I SHAEMPLOY PERSONS SUBJECT TO WORSOAM't COhl I ATION LAWS OF <br /> CALIFORNI H MP CA1 MWT f LL M MOM1t I AWAMCE FOR ALL REOUNIFO�INIItPFL OMt AT Lt06 VSJ{.33-}COMPLETE DIIAWING AT IDWEII AREAyP�IIOVIDED. <br /> sle..a x // TIB.9 0- Ort d�!7•A <br /> BOT RAN ID,—w SW l SUI. <br /> L. NAMES OF STREET OR R OROS NEAREST TO OR BOUNCING THE PPOPEIRY, 1. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR BOPO6ED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF GEWAGE DISPDGAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LDCATUDN OF ALL EXISTING AND PROMSED G. LOCATION OF NEED WITHIN MDIUG OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED MEAS SUCH AS PATIOS.ORIVEWAYS.AND WAMS. ON THE BIOPERTY OR ADJOINING PROPERTY. <br /> 1�. <br /> . h <br /> DEPARTMENT USE ONLY q \ <br /> APwloll..APpP[.1 By wm ' (� A,,, <br /> 01.1.BY wu RIPP Ir.pcVe.BY C <br /> D�n.cHon I.N..ttro.BY w<e <br /> C..:— <br /> ACCOUNTING <br /> .... :ACCOUNTING ONLY: MDI FACT <br /> PE CODFL FEE INFO AMOUNT RBAITTEO CHECIU/CASH RECEIVED BY DATE P ITIAERVICE REQUEST NIUMBER I INVOICE <br />