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i <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> IftemirAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O• BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9,5201388 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> ial <br /> APPLICATION IB NEFE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTMNDAMI INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE Woll SAN <br /> JOAQUIN COUNTY DEVELOPMENT TELE,CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES•ENVIRONMENTAL HEALTH OMSION. <br /> JOB ADDRESME,APH.-LR / 1Ub$l d (� T�YH'18UF�L Rd PITY L-k <br /> ,T (- t PARCEL SIZVAPNI <br /> OWNER'S NAME—cl Lj� 6tp Lk ran ADDRE883457 <br /> CONTRACTORA1,I�F/h1m�dn <-r PHONE <br /> �N� 1 LrOS Sp a C. ADDRESS��T E�OX C(1? SAir [ icl LICE PHONE#207 AIM <br /> SES CONTRACTORlM <br /> (�Px a DrLlq ApD11E8R5SD Mar�lnrz UCI /� RHONE FJ/D��� (� <br /> TYPE OF VYEEL/RIMP, W NEW WELL ❑ NEPLACEMENT WELL MONITORING WELL EAAWJO 00)4) ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑New❑Rgelr <br /> RYPE OF PUMP) N.P. DEPT"PIMPSFT FT. FIRST WATER LEVEL p <br /> 11OUT-OF-SERVICE WELL 11GEOPHYSICAL WELL E ❑ SOIL BORING R <br /> 1:1 DESTRUCTION <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION � IIS_ A <br /> DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMEBTICAMMIVgtE 1�1 GRAVEL PACK/SIZE 3(.MLc}W TYPE OF CASINOISTEEL/PVC fit DIA.OF WELL CASING_ '2 " <br /> ❑ NSLICAIUNICIPAL ❑DRIVEN 54nq DEPTH OF GROW SEAL 9'w 1•.E� SPECIFICATION R <br /> ❑ IRRIGATIONIAG 11OTHER GROUT SEAL INSTALLED BV )I{.4y GROUT BRAND NAME Ip E <br /> MONITORING GROUT BFAL PUMPED:�Yr r❑Ne CONCRETE PEDESTAL BY DRILLER:OR Y. ❑Ne S <br /> APPROX.DFPTH LOCKIND CHESTER BOMMOVE PIPE 5 <br /> PROPOSED CONSTRIICTION(DRILUNG METHOD: MUD ROTARY AIR ROTARY AMER)_CABLE OTHER <br /> 1 HMRY CENT" 1 HAVE PREPARED THIS SNVCAiON AND THAT THE Nbq(NRIL BE DONE IN ACCORDANCE WIN BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT HB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONIRACTOR'B HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA. HE APPUC IT US IN ADVANCE FOR ALL RMU S)INSMTONS AT VKHR AgJA22. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> IS._x � 161J�Q'1 TIRe._��j'�///Jl <br /> PLOT PAN IDrew b SeNwl PaNe •ro <br /> 1. NAMES of STREETS OR ROADS NEAREST TO OR BOUNDING TIRE PROPERTY. B <br /> dPOBAI SYSTEM On AOP(IBEH <br /> A. LOCATION OF HOUSE SEWAGE <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE pIADE N MBTEMB. <br /> 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUMMED FIFTY fT. <br /> BTRUCTVREe,INCLUDING COVERED AREAS SUCH AS PAlIOt,DRIVEWAYS,AND WglAB. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> � itt, lMu� I}ti�(bP� <br /> DFPMTMMT USE ONLY qA� ILy1 <br /> A,,Kcwbn APeeeLM BY Deb �,Il•� l '� Ar.e <br /> Grain bI ".BY Det. PenP lneoeullen BY V.I. <br /> DeelnNlbn Ir.Prnlbn By <br /> eaU <br /> ACCOUNTING ONLY: AIDE FACE <br /> PE COD" FEE INFO AMOUNT SWATTED CIIECKEMASH RFCBVED■Y DATE PERMIT/SFAICF REOUFST NUMBER INVOICE <br /> b b o.2 . D I S-1(YZ <br /> Pub.Health Sow.-En Aro.173(3/96) <br />