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APPLICATION FOR WELLIPUMP PERMIT „ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201388 <br /> (209) 488-3420 � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �' • A, <br /> (CemplEh in TrpliuGl <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAWIN COUNTY DEVELOPMENT TITLE,CHAPTER 81116.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC H SE <br /> HEALTRVIO S,ENVIRONMENTAL HEALTH DIVISION. <br /> v� ✓ N-f� SSS-Z6o-! 3 <br /> Joe ADGRESB/OR APNB Z.S� ST STMT /(',y.NTR j3'L Crry �4PU/ !_� PARCEL SITE/APN# <br /> OWNER'S NAME e7C✓,16F_ ADDRESS Po 9 c aL�.3, VF�agu,(,GA- mil <br /> 2 <br /> CONTRACTOR �EafoN ADDRESS //375" °fit'./u/Iss� UGIT/6rZ5 PONEF Q'//J7 <br /> _ pAscrc O.¢rv� <br /> BUB CONTRACTOR ADDRESS UCY PH��ON��``EN QQ `JI <br /> TYPE OF WEIl^MP: ❑ NEW WELL 13AC <br /> REPEMENT WELL 11 <br /> MONITORING WELL Y 13 OTHER —(_,/J <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTmN WELL# J <br /> ❑Now❑R.P.Ir N.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP /1 LL <br /> ❑ OUT-0FBERUCE WELL ❑ GEOPHV6ICAL WELLY BOIL BORING�/N�OIJ.JNT B <br /> ❑DESTRUCTION: O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION Z /.Lrc V- DIA,OF CONDUCTOR CASINO 0 <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TVP OF CASING/STEELIPVC A/Fi DIA.OF WELL CASING D <br /> ❑ MOUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IFJUGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL N1MPED: ❑V- le CONCRETE PEDESTAL SY DNUFR:❑Yr []No S <br /> APPROX.DEPTH h /��Y� LOCKING CHESTER BOX/STOVE POPE S �) <br /> PROPOSED CONSTRUCTION/ORIWNG METHOD: MUD ROTARY AIR ROTARY AUGEfl CABLE OTHER 01"4r .a✓.fit 1 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE W01K WILL BE DONE IN ACCORDANCE WITH SAN MAGUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND C <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH C' <br /> THIS P IMIT IS ISSUED,1 SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOU—OWING;/j 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.• PLICANT MUST CALL M HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 130111 4SBJ423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> BIPrr.1 x Till: Q --J,71, C�-OteVOJT <br /> NOT PUN mrF to SCN.I So.l. •to <br /> 1. N BOF STREETS OR ROADS N BT TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROMISED }� <br /> 2. O LINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ^� <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PFK)MSEO S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAUUS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> a49 CN <br /> fcR3 <br /> In if <br /> {-LJJG{ � • PszraRal.cD. <br /> jr4 ri o.v <br /> %1/rA-at�t� r <br /> 0 <br /> DEPARTMENT USE ONLY �/�, �/.�,.,' <br /> Appliwtlon AccWtocl BY I ` - DN.S �Are. <br /> G'..I—Pocllon BY �,T: �LYL�L/�Q��'� D.1 Pump Impecton BY c Ort. <br /> Doo".'inn Inpontbn 8, Dp. <br /> C.mm. .M (, rni Mt,�2 __.I/]pu/ oY 1.J(7i L_. M(J,�iE /1'1n/J/lil <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNTREMITTED CHEC"/CASH RECBVEDBY DAT PERMITISERNCE REQUEST NUMBER INVOICE <br /> S D O 03 45 <br />