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APPLICATION FOR WELL/PUMP PERMIT <br /> r , <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> p ( , •� (209) 468-3420 <br /> NOM•REFUNpA u PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1C9mpi&t&fG TripReal&} <br /> APPLICATION IS OiERE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND70R INSTALL THE WOFW DESCRIDEO,THIS AFRICATION 18 MALE IN COMPLIANCE Wilt)SAN <br /> JOAQUIN COUNTY DEVELOPMENT TrfLE7,CIIAPTER 8-1115.3 AND T14E STANDARDS OF DAN AOUIN COUNTY PUBLIC ILEA 711 eERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODFIES3/OR APNF C � - CITYPA EL BIIFJAPNf <br /> FOWNER'S NAME _ ADDRESS bNE <br /> CONTRACTpR - - _:Z ADDRESS AJC► ki Yd 1,1401,1E F C f <br /> 7r' <br /> SUB CONTRACTOR ADORESS 13Cf MIONE f <br /> FTY LPI <br /> OF WELJMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL f 11OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR - ❑ CROBB-CONNECT REPAIq <br /> © VAPOR EXTRACTION WELL f <br /> F <br /> ❑N"^'� � 14•P•� DEPTII PUMP BFT FIRST WATER LEVEL <br /> TTYPE OF PUMP) • <br /> ❑ DUTOF SERVICE WELL ❑ OEORIY8ICAL WFLL/ ❑ SOIL BORING S �� <br /> ❑DEBTRVCTION: <br /> -INTENDED USE TYPE OF WFT1 CDNSTRLJCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO D <br /> FF} <br /> O'DOMESTIC/PFIVATE ©GRAVEL PACXJSITE TYPE OF CASINOIBTEEIFVC DIA.OF WELL CASINO d <br /> ❑CT PUBUCIMUNICIPAL ❑DRIVEN bEPTIi OF OROUT SEAL SPECIFICATION <br /> F❑ IFtRIOAT10NJAG ❑OTHER GROUT SEAL INSTALLED BY14 ' <br /> GROUT BRAND{.TAME f <br /> r -.❑ MONITORING GROUT SEAL PUMPED: ❑Yes ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No ,s <br /> APPROX.DEPTH_ --�L -�. IOCKIN43 CHEBTER BOXJBTOVE RPE <br /> S { <br /> ('"'?ROPO SEp CON97RUC TIO NlOPot.UNd METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> ..1 IOMBY CERTIFY THAT I IIAVE PREPATLED THIS APPLICATION AND THAT T14E WOFK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND PULES AND <br /> REGULATIONS OF T14F BAN JOAOUM COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOVANO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WoryL FOR <br /> WIi1C11 <br /> T1418 PERMIT 18 ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CALIFOIIFSA.- CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTFFIE� <br /> HE FOLLOWING: 'I CERTIFY TIIAT M TO RFORM E OF THE WORK FOR VAOCH THIS PERMFf IS ISSUED,I I HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM SATION LAWS OF <br /> :ALIFORHIA' PPUCANT MUTT C 11 NO IH OF <br /> FOR ALL REOUStED INSPECTIO'NJ&AT 12091 FSS-7113. COMPLETE DR/1W1Np AT COINER AREA P'ROV`IDED. <br /> + 8[pned X Tltl•-��C S' ...._.. _bale / <br /> PLOT PLAN SAew to Soet•I Scale •to <br /> NAMES OF STREETS OR FIGADB NEAREST TO OR$10UNDINO THE PROPERTY. 4. LOCA7 PON OF IIOUBE BEWAOE DISPOSAL SYSTEM OR P1IUPOSED <br /> '. OUTLINE OF T14E PnOPERTY,OIVMIG DIM£N81ONS AND NORTH DIRECTION. EXPANSION OF SEWAGE 618P08AL SYSTEMS. <br /> J. DIMENSIONED OVRLJHEB AND LOCATION OF ALL EXISTING AND R10Pg8ED S. LOCATION OF Wt LLS WITHIN RADIUS of ONE HUNDRED FIFTY FT. <br /> ` STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPEgTY OR ADJOINING PROPERTY. <br /> ��JCJ r <br /> :�. . <br /> A L1 <br /> 7r <br /> I <br /> DEC 3 3998 <br /> CIO-? <br /> "�Pll�iL C HFI;I i t <br /> ......... .: ... . <br /> ENVIiZ. <br /> NM ENTAL HF.4111i nivp li nv <br /> .. <br /> DEPARTMENT U69 ONLY r/ <br /> Appftsll•n Aacwted D•e• <br /> areal Irnveollen BT b•1• Arne Wpsctl•n By Date - ;2- <br /> [7„•Irlrcll•n 1.,•nselbn Dy <br />�- 17n• <br /> 1 <br /> .ACCOUNTING ONLY: AID/ FACE <br /> PE CODES FEEINFO AMOUNT REMITTED CIIECK fCA&H RECDVED Sy DATE PERMITJ&E71V1cE REOVEST Hl1MBFA INVOICE <br /> r <br /> C1.15-75) L ) <br /> i <br /> f <br /> Frl­h 171 n In-+. . <br /> q.. <br />