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LICATION FOR WELL/PUMP PERMIT /,J <br /> ~ SAN J,,,%QUIN COUNTY PUBLIC HEALTH SERVICES � I'004)fe 0/ <br /> ENVIRONMENTAL HEALTH DIVISION ," <br /> �^ 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> q (209) 468-3420 P(1 ,�/y+' <br /> RON•REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> {CBmplrlr IR Tllplkatal <br /> F' APPLICATION IS HERE BY MADE TO TIIE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INStALL THE WORK OESCR1nw.THIS APPLICATION IS MADE IN COMPLIANCE Willi SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF B JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APNf CITY <br /> PARCEL BIZEIAPNR <br /> OWNE11'8 NAME ADDRESS 1 \ <br /> r11DNE r <br /> CONTRACTOR AbbnEae — LICr A 4 PHONE�r��E <br /> BUB CONTRACTOR ADDRESe tic# PRONE t <br /> TrrEOF WELLA-UMP: © NEW WELL ❑ REPIACEMENT WELL ❑ MONITOIVNG WELL f ❑ OTHER <br /> �^ ❑ INSTALLATION- ❑ WELL BYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r <br /> II OF PIIMPI ©New V coir H.P.-6n DEPTH PUMP SETGi:- FIRSt WATER LEVEL O <br /> I� ❑ OUT-OF-SERVICE WELL ❑ OEOMIY61CAL WELL r © SOIL NORINO B <br /> ❑OE6TRUCYION: <br /> IHTENOEd USE TYPE OF WElI, CON:7, STRUc71OH SPECIFICATIONS A <br /> © INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CARING D <br /> ❑ nomm IC/PIUVATE ❑GRAVEL PACKISiZE TYPE OF CASINOISIEEUPVC OIA.OF WELL CASINO O <br /> yr ❑pp PUBLIC/MUNICim ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION H <br /> W SpUGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY <br /> ORQtf7 BRAND NAME E - <br /> 1 - ❑ MONITORING r GROUT SEAL PUMPED: ❑Ys ❑No CONCRETE PEDESTAL RY DIULLEm Ely. [IN. 5 <br /> APPROX.DEPTH /8--o <br /> LOCKING CHESTER BOXIBYOVE PIPE S <br /> PROPOSED CON$TRUCTIONn119LUNG METHOD; MUD ROTARY AIR ROTARY <br /> AUGER CABLE OTHER <br /> — <br /> I NMRY CERTIFY TIIAT 1 HAVE PREPARED TI418 APPLICATION AND THAT THE WOFK WILL BE DONE 1N ACCORDANCE WITH BAN JOAOUIN COUMY ORDFNANCEB,67'ATE LAWS,AND 1`11A Ell AND <br /> REOULATIONS OF TIIE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES TIIE FOLLOWINOt'I CERTIFY THAI IN TILE PERFORMANCE OF THE WOFK Fon Wlllc4i <br /> THIS PERMIT 1816OUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S FIIFUNO OR SUB-CONt AACTING SIONAT IFR£CERIltiEB <br /> THE FOLLOWIN ERTIFY THAT IN THE ORM E OF THE WOFK FOR WHICH THF8 PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATID LAWS of <br /> CAIIFO 104E A CANT MUSY C 4 NO IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT t29914"4423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> ; ► ��rr'yy`�� <br /> ell <br /> Bl9ned X Tltl.__ �/!�1. ._ ,_, ,�_Oat• I <br /> l PLOT PLAN IOrm to Ba.lal Sado 'to <br /> i 1. NAMES OF RTKETS OR ROADO NEAREST TO OR BOUNDING TIIE PROPERTY- <. LOCATION OF HOUSE SEWAGE DISPOSAL BYSTEM on PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. <br /> EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 3, DIMENSIONED OUTLFNEB AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED fIFTY Ft, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIX8, ON 104E PNOF'EFlfl'OR ADJOINING PROPERFY. <br /> .. .....,.. - ..,.. _ c� <br /> 1 <br /> f' ryY f$i 9/y <br /> �A, <br /> o <br /> C <br /> o <br /> Vi <br /> TOJ/J� DEPM7 USE ONLY <br /> ... -AnpllteNan"Aaee�lrat.A7-� - T. .. ..,,1'. ^. J .�Yi .,..r:..,� <br /> Dat• <br />`- GaVI Inapeollan By Da!• Pvnp Inapectlon By <br /> 0-upcllon Inap-11-By <br /> Da■ <br /> Comma+la: <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODS FEE{NFO AMOUNT REMITTED CIIECK 1cAN1 RECEIVED RY DATE PETTFVIITIIFTIVICE REQUEST NUMBFR INVOICE <br /> Zia <br /> F Pub.Health Sarv.-Einviro.173(1197) <br /> Y <br />