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LCAT'ON <br /> FOR WELL/PUMP PERMIT <br /> SAN CbUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 / pu4 <br /> (209) 468-3420 <br /> R—p �}0 n� MOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IL !' (Compkis In TripRallnl <br /> APPLICATION i8 HERE BY MADE 70 THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DE6CRIBEO,71118 APPLICATION IS MADE IN COMPLIANCE Willl SAN i <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-111 5.3 AND 711E STANDARDS OF B JOAQUIN COUNTY PUBLIC IIEALTII SERVICEB,ENVIRONMENTAL HEALTH DIVISION. <br /> F <br /> JOB AOURESSIOR APNI f .ter - <br /> CITY [ PARCEL SIZEIAPNI <br /> OWNER'S NAME ADDRESS i'I1ONE I <br /> e CONTRACTOR AbbREBS L1C+T ,. d P1tOIlE 1�7� �Lt� <br /> SUB COWFACTOR ADDRESS UC! PHONE <br /> rTYPE OF, F WELLJPIIMP• ❑ NEW WELL © REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> (^ ❑ INSTALLATION ❑ WELL SYSTEM REPAIR 13CROSS-CONNECT REPAIR 11VAPOR EXTRACTION WELL I <br /> f <br /> �/571 MPI ❑"�'/ RTepelr H,p. DEPIN PUMP SET 45EI FiReT WATER LEVEL <br /> " ❑ OUT•OF-BEftvtCE WELL ❑ GEOPIIYBICAL WELL E Q SOIL BORING - B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE Of WELL CONiTR1yCTION EpECIFICA IONS <br /> ❑ INDUSTRIAL ©OPEN BOTTOM DIA,OF WELL EXCAVATION n <br /> _1 b1A.OF CONDUCTOR CASING❑ UOMEBTICIPRIVATE 11U <br /> GRAVEL PACKISIZE TYPE OF CASWO181 EEPVC OIA.OF WELL CASINO p <br /> ❑ PUBLIClMUNICIPAL ❑DRIVEN DEPTH OF ORCUrr BEAL SPECIFICATION O <br /> IRRIGATIONJA0 ❑OTHER GROUT SEAL INSTALLED BY OROUT BRAND NAME E <br /> © MONti ORiNO (, r GROUT SEAL,PUMPED: [IV. <br /> ❑Nv CONCRETE PEDESTAL BY piALL£R:❑Yr [IN. S <br /> APPRO%,DEPT H__ __ D �1 _ LOCKINO CHESTER 80XISTOVE PIPE <br /> s <br /> MIOPOSED CONS TRUCT10NMftjJJNG METNOO; MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I IIEREBY CERTIFY THAT 1 IfAVE PREPARED THIS APPLICATION AND THAT TIIE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,WATE LAWS,AND RULEB ANG <br /> REGULATIONS OF Tilt BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TIIE FOLLOWIHCI:'1 CEMIFY THAT IN TIIE PEIYORMANC£OF TIIE WORK FOR WIIICII <br /> THIS PERMIT IB I6e11ED,1 BIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S III(IHO OR SUB-CONIRACIING MONAT III C£R11r1I;B <br /> TIIE FOLLOWIN ERIIFY THAT IN TIIE ORM E OF THE WORK FOR WlklCH TIIIB PERMIT IB ISSUED,1 BITALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIO LAWS OF <br /> CALIFo 712E A CANT MUST C TNT IN ADVANCE FOR ALL REQUIRED INaPECTION6 AT 42061406-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> _ r <br /> Sl6ned A <br /> Dae <br /> PLOT PLAN(Drew to Saide!Bade 'to - <br /> 1, HAMER OF STREETS OR ROADS NEAREST 70 OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On Prior ED <br /> 2. OUTLINE OF THE PAOPERTY,OIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL BYSTEMe. <br /> a. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTINO AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE iIUNOtgD FirPY F1. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> (� rVil <br /> ill f�,F <br /> ?... /Vol <br /> IIS. <br /> P <br /> �.. <br /> H � <br /> I <br /> v I . <br /> �-` f/V1! DEPART E VSE ONLY <br />._-. Arrllear�n Ag.&pted'BY�;..._ - - a.. •;.�J'^�"' -er.,-_ -- - I- <br /> G.o,A IntlPrllan OY Del. Pump I—Pmkl.n By <br /> k ilnauAtl.n(rnPxlkon By <br /> y� Dae <br /> C.mmnlltl• <br /> ACCOUNTING ONLY; Alp/ FACT <br /> PE CODES FEE tNFO AMOUNT REMITTED CHECK MA611 RECEIVED BY DATE PETIWTI6191VICE REQUEST NteNBER INVOICE <br /> 05 - rr z � <br /> L <br /> Pub.Health Serv,-Enviro.173(1197) <br />