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( � APPLICATION FQR RF.ELJPUMp PERNiIY -. .. .-. _. .. . ..._ <br /> BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> F 0 BOX 9811,445 N.SAN JOAOUIN ST.STOCKTON,CA MOS-311111 <br /> i Ix081 <br /> 498-MO <br /> 1..d•L � �L � RON•RffIIMOAtILE PEHNIR EIIWBEp 1 PEAR FUN DATE ISSUES <br /> LOMpNis 6 Ti4+WMW <br /> Application is here 14Y meds to the Son Joaquin County for a permit to construct and/or install the work described. This application is <br /> made in ceapliance with Sen Joswin County Devetapment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Exwironowntal Health Division. /� <br /> Job Address/or AFx! �i� r C? �O—p C-' City taw, 7jC22 'Ferrel Site/APVS .Z©[7e� <br /> oewrr•s Nasm '! Address 3p .� .Phone Ig <br /> Contractor ` Address Licg 77q/90�F'horne elAgZ <br /> gib Contractor i Address Licit Phone■ <br /> TYPE R ..L1HiL/PUFFp: I�,' NEN WELL [I REPLACEMENT WELL [1 MONITORING WELLS U OTTER <br /> � 111 DESTRUCTION 13 OuT-OF•SERVICE WELL 0 GEOPHYSICAL WELL 0 1] 9u)IL BORING <br /> k � <br /> INSTALLATION h WELL SYSTEM REPAIR 11 CROSS-CONIIFCT REPAIR Q VAPOR EXTRACTION WELL R <br /> [I New q Repair H.P. L7 DEPTH PUMP SEi FT,. FIRST WATER LEVEL <br /> (TYPE OF P MF) <br /> INTENDED USE TTPE Of tYELL INJI RUCTION NPECRCATign <br /> D INDUSTRIAL - III] OPEN BUTTON DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING k <br /> p OOMESTIC/PRSVATE !I![) GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC OCA. OF WELL CASING <br /> [) PUBLIC/MUNICIPAL jIt) DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> IRRiGATIOR/AG 'I`11 OTHER GROUT SEAL INSTALLED BY _ GROUT BRAID KW- <br /> MOM <br /> AME nary <br /> MONITORING GROUT SEAL PUMPED: II Yes [I No CONCRETE PEDESTAL BY DRILLER-. 0 Yes [] No u <br /> APPROX.DEPTH ! LOOKING CHESTER BGX/STOVE PIPE <br /> PROPOSED CONS11=11O11IDRILLUNS METHOD: MUD ROI AIR ROTARY_.AUGER_CABLE OTNER_ <br /> I hereby rartify that I have prepared this application ad that the work will So done in eocardsnoe with Son Joaquin County Ordinenoa, <br /> Stets Laws, and Rutes and Regulations of the Sen Joaquin Canty. Rose owner or licensed agent's signature certifies the fo(lowirgt ■1 <br /> certify that in the performance of the work for which this permit is issued, 1 shall not splay persons subject to,WORKNAN'S COMPENiNICl[ <br /> Laws of California."I Contractor's hiring or cab-contracting signature certifies the following; " 1 certify that in the performs a <br /> II of the nark for which'this permit Is Issued, I shall esptoy persons subject to WORKMAN•G COMPENSATION Laws of California." THEAPPLEW <br /> MUST CBVANCE FOR ALL IUD INSPECTIONS AT 090 4B[E2421. Complete drawing at I r area provided. �b <br /> Signed= TItle Date/Jelle <br /> ^ <br /> �;i <br /> PLOT PLAN (Draw to Scale) Scale <br /> 1, Races of atreetsjar roads nearest to or hoing the property. 4. Location of howomwe" disposal system or (d <br /> 2. Outline of odea the property, giving diskeaeions and North direction. proposed expansion of sewage disposal systems. 31 <br /> 3. Oiaensiated outlines and location of all existing and proposed 5. Location of walls within radius of 150 ft. on <br /> structures, including covered areas such as patine, drivawaya, the property or adjoining property. <br /> and walks. <br /> III <br /> r <br /> "'Rill 11 1 <br /> o'tl <br /> Lt R <br /> YM M <br /> i <br /> N <br /> 1J AO INEN IRO h�E TA HEUSE ONLY <br /> P43ptication AcceptedJBy 0 to .'� !6 r! <br /> Area <br /> f <br /> 1 Grout Inspection By. Date t tion L <br /> F. Pulp nspet M Data <br /> Oestruction Inspection By nate Cpetperrta <br /> • ACCOURM 911LT: �. AIOI FACl <br /> PE C60iN IN INFO AMOUR REMITTED (09iACASM NECHYEO R GATE /EiNIT(NCiY[CE' HNNRB INYON+E <br /> js <br />