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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 y <br /> (209)468-3420 <br /> NOW-REFUNDABLE PERMIT EXPIRES 1 YEAR FROYA DATE 18SUED <br /> ' ICompl$t$In TrlpRelt$I <br /> � AMICATION 18 POEM RY MADE TO THE SAN JOAGMN COUNTY FOR A PERMIT TO CONSTRUCT ANO/on INSTALL THE WORK DESCRIBED.71118 APPLICATION t8 MADE IN COMPLIANCE WITH SAN <br /> I JOAQUIN COUNTY ofVELopmENT TITLE.CHAPTER 8-1115.3 AND TRE BTANOARDB Of SAN JOAQUIN COUNTY PUBLIC}HEALTH SERVICES,ENVIRONMENTAL HEALTH DrwatON• <br /> JOn ADOREBRIOR APHI 47 / +1� <br /> gg�� / CRY (,�� Gia-t��.,. PARCEL SIZEIAPHI /� ] <br /> trWNEn'B NAME �.. Ia Q I/ �a�t4c. ADDRESS 1'• 4'. /� [ r P PHONE f Z C7 3 <br /> COHIRACTOR �rit✓ L AVOME88LIC/ 1+IIONE f <br /> t, BUS CONTRACTOR ADORES11 LIC/ PHONE f <br /> Type OF WELUPUMP• ❑ NEW WELL ❑ REPLACEMENT WEII ❑y MONITORING WELL f CI OT11ER <br /> - ❑ INBTAtLATPON ❑ WELL SYSTEM REPAIR ❑ CMO88•CONNECT AEPAIA ❑ VAPOR EXTRACTION WELL f <br /> ❑New❑Rmeh H.P. DEPTH PUMP SET rT• FIRST WATER LEVEL O <br /> OF PUMP) - <br /> ❑ OLTT-oF-BEAVICE WELL ❑ GEOPHYSICAL WELL S ❑ SOIL BORNO B <br /> EBTRUCTlON; 41 42 i r- <br /> 1NI��`�ENOED UiE I YPE or WaL CONSTRUCTION 8PECIFICATIONS A <br /> '❑ INDUSTRIAL. ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.DF CONDUCTOR CASINO O <br /> '❑ DOMFBTtC/PMVATE ❑GRAVEL PAdUSIZF TYPE OF CASINOIBTEELM-M 01A.OF WELL CASINO D <br /> CI PURI.MmUNrCrrAL ❑DIIVEN DEPTH OF GROUT BEAT SPECIFICATION q <br /> i❑ lnRrOAT ION/AO ❑OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME <br /> IF <br /> .❑ MoMTbRING anow SEAL PUMPED; ❑Yr. [:IN. CONCRETE PEDESTAL BY DRILLER'❑Yrt ❑No 5 1 <br /> APPRON.DEPTH LOCMNO C"EdtER BOXINTOVE PSE S J <br /> 'PROPOSED CO NBTMUCTTONIDWLLINO METHOD; MUD ROTARY AIR ROTARY AUGER CABLE OTHER - 1J <br /> 7 HE9ESY CE111IFY THAT 1 HAVE PREPARED THIS APPUCATPON AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDWANCES,STATE LAWS.AND RULES AND <br /> 'REOULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEPVORMANCE OF THE WGRC FOR WIIrCPI <br /> '71#16 PFIIMIT 18 100M.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPERIATION LAWS OF CALIFORNPA.- CONTRACTOR'S TTtRNTG On su"oRTRACTING SIGNATURE CERTIFIER <br /> THE FOLLOWING• •1 CERTIFY THAT IN THE PERFORMANCE OF T1fE WORK FOR WHICH THlB PERMIT IR IBSUEO,1 SHALL EMPLOY PERSONS SUBJECT f0 WORIMAN'S COMP4NBATION LAW$OF <br /> 'CAUFORHIA.' AAP,PUC�ANT MUGCAURS IN ADVANCE FOR ALL REOMID 1N11PIEC7tlame AT IEO0I4004121. COMPLETE DRAWING AT LOWER AREA PROVIDED, <br /> � �r <br /> Blvned k `+'�WLLiY•Y (r TI1le ��7'�Y Dn• �(! w /d <br /> PLOT PLAN IOrow to$aN+l So+lr 'is <br /> .1. NAMES OF BTREETS OR ROAOB NEAREST TO OR BOUHOM THE PRDPEATY. 4. LOCATION OF HOUSE SEWAGE 1118POSAL SYSTEM On PROI.OSED <br /> Z. OUTLINE OF lIft PTtOPERTY,OnRNG DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2, DIMENSIONED OUTLINES AND LOCATION OF ALL EX1@TWG AND PROPOSED B. LOCATION OF WELLS WITHIN RAWUS OF ONE Hl1HOMED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,ORVEWAYS,AND WALKS. ON TIB;PROPERTY OR ADJOINING FRoFE11TY. <br /> :. <br /> PAVM EN <br /> AUG -27 1998 <br /> SAN JOAOUIN COUNTY <br /> RVq <br /> EhlUtfidhll�41IJ7A HEA <br /> TH p SICir, <br /> OEPARTMIENT UI!ONLY <br /> 7 <br /> APRIIe+lion Anaepted BY J brtr <br /> Mw� <br /> I <br /> aroM In PMIL_By Ir rump Inrpwtlon BY Dal+ i <br /> I)MI,IWH+n tmpeotlon BY �] 1 <br /> A V i <br /> ACCOUNTING ONLY: AID/ FACS <br /> PE CODES FEE 1NF0 AMOUNT RT]IMTTED "ECR/)AG" RECEIVED BY DATE Ps"ITISETRVICE REGMT NUMBER INVOICE <br />' Pub Health Serv.-Enviro.173(1197) <br />