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APPLICATION FOR WELL/PUMP PERMIT �t-y <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> LON•REFUNOABLE PER EXPIRES 1 YEAR FROM UATE <br /> APP135UEB <br /> fCBmpAt!1G TripBEBt+► <br /> + LICATION IS HERE BY MADE TO THE SAN JDAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WTTII SAN <br /> JOAOUIM COUNTY DEVELOPMtW T71'TLE,CHAPTER 9.11 3 3 AND THE STAND BDB of SAN JOAOUIN COL BUC HEALTII SERVICER,rNVIRpNMEATAI HEALTH bM SOON, <br /> RE <br /> JOB ADD69MR API / <br /> / —9 <br /> PARCEL 812 EJAPNI <br /> I{ <br /> OWEfl'B NAM I ADDRESS SO• Q 1 <br /> PHONE! <br /> CONTRACTOR� S ADDRESSO Z' <br /> LIC1111�� IWbNE/ - <br /> SUBCDNTRACTOfl ADDRESS <br /> LOC! MORE a <br /> TYPE OF WE_LLA'UMP: ❑NEW WELL ❑REPLACEMENT WELL I❑MONITORING WELL• ❑y OTHER <br /> J /f�_ T❑� Bl/B7�U.ATk)H ❑WELL B/Y'1EM REPAIR y CROB$tONNECT REPAIR EJ VAppR EXTRACTION WELL/ <br /> 11R{rw lel Replk NMP SETlS FIRST WATER LEVEL._,_ <br /> (TYPE OF MMPI <br /> CI <br /> ❑DEBTRUtYION: OUr-OFSERVICE WELL Q OLORPISMAL WELL ❑ SOIL BORING <br /> e <br /> ' <br /> ' INTENpEb VSE TYPE OF WFLL CONSTRUCTION iPECIFICATIONS <br /> ❑Iryy'_ 6TlBA <br /> � AL ❑OPEH8OPTpM DIA.OF WELL EXCAVATION SNA.or CONDUCTpR CABINO <br /> i��/DOMEeTICR'ipVATE ❑ppgVEL PACK1872E O <br /> TYPE OF CAS1NOMI EEL/PVC D1A.OF WELL CASINO <br /> O <br /> ❑NBIICA.IVNICI7'M ❑bRYEN DEPTH OF GROUT SEAL SPECIFICATION I <br /> + <br /> II--�1 A IIIRGATION/AO L.1 OTHER GRauT SEAL INSTALLED BY GROUT BRAND NAME f <br /> Trryry <br /> El MONITORING GROUTGROUT SEAL NMPEb:[3y_ ❑Ne CONCRETE PEDESTAL BY DRILLER:Ely- [IN. g <br /> APPRO%.DEPTH E►TH LOCKING CHERTER BOX/S7OVI;APE - S - <br /> PROPOSED CONBTRUCHOR/DRItLINO METHOD; MUD ROTARY AIR VOTARY AUGER CABLE piHFR <br /> I HE9ESY CERTIFY 711AT t HAVE PREPARED THIS APPLICATION AND THAT THE WOM WILL BE DONE IN ACCORDANCE WITH BAN JOAOUPN COUNTY ORDINANCES,STATE LAWS,AND RULES ANb <br /> REGUTA710N8 OF THF OVIN COUNTY.HOME OWNER ENSED AGENT'S SIGNATURE cERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PL ,181{All T EMNLOY S BVB T O WORKMAN'S COMPENSA71 LAWS OF CALIFORNIA,'CONTMCTOR'9 HIRING OR BIIBCOMRACTO{p SIGNATURE CERTIFIES <br /> THE FULL CETR 7 IN TI O HE W4 7S rr IS IBS D.I SHALL EMPLOY PERSONS SUBJECT TO WDRIMAN'S COMPENSATION LAWS OF <br /> CAL MORNI T APPLI MUST C ANCE R All REOLIINED 1 8 AT p u2m.COMPLET WINO AT LOWER AREA PROVIDED. <br /> BISnM X Thl! � <br /> D.n-_ <br /> ROT PILIN M7—to B ej B.N� •Ln <br /> 1.NAMES OF StATETe OR ROADS NEAREST 70 OR BOLIIANNL{THE P'ROrERrY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P MPoSEO <br /> OUTLmE OF THE FRO11."NO IIMENBIU.9 AND RORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SY87EM8. <br /> `FFF i.DIMENSt .D OUTLINE.B AND LOC--N OF ALL EXISTING AND PPOPOSEO B.LOCATION OF 1N[ill VWTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STAUCTVREB,IJCLUIXNG COVERED AREAS SUCH AS PATIOR,DRIVEWAYS,AND WAtXs, ON THE PROPERTY OR ADJOINING PDOPLRIY, <br /> . . : CIO r a r <br /> �. . <br /> .. <br /> U <br /> v .. <br /> (...... <br /> ... <br /> .. <br /> �..... i L <br /> : :. _ <br /> sIWe <br /> ^�01 <br /> v�ror s °4tR9T <br /> Al <br /> .. <br /> j <br /> . 1 <br /> + DEPARTMENT USE ONLY <br /> F + <br /> II <br /> �II 4 <br /> I <br /> 1 <br /> y <br /> } <br />