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6-0/74PPLICATION FOR WELL/PUMP PERM'" <br /> SAI ,OAQUIN COUNTY PUBLIC HEALTH SE._ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 Ge� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplet6 In 711plk6t61 <br /> AP`UCATION 19 HERE BV MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMFLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TRLE,,C�H/APTER�-9-11,1115.3 AND THE STANDARDS OF SAN JOAQUIN C/OUNTY PUBLIC IHEEALTrII SERVICEy..ENVIRONMENTAL HEALTH DIVISION. <br /> JOB <br /> TY <br /> OWNER NAMERAPNI U—! O/O� � �' �d ADDRESS �ILYL()P�I AfI `O��IZEFHONEI 36Z-o8�. <br /> OWNEP'P NAME W !E-�� Q 9 �/ yq <br /> CONTRACTOR D�l +-a -PLA MELS ADORES81 (nDOX I /Z/ UCI&Z373MIONEI �6 _%42 <br /> BUB CONTRACTOR ADDRESS UCI PHONE/ <br /> TVPE OF WELLTUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MOND ORING WELL E ❑ OTHER <br /> ❑ INST�A�LI"" N ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT R PAIR ❑ VAPOR TRACT WE E <br /> . .�- ❑Nw Ll Pep.lr H.P. 4 DEPTHIVMPS7W FIRST WAT L Ot•— <br /> RYPEOFPUMPI /A/rn II <br /> be'�elope Vu( ❑ OUT-OF-SERVICE WELL ❑ HEORIY6IGLWELL/ ❑ SOIL 5 (1 <br /> ❑DESTRUCTION' f``l~I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMFSTIC5'HWATE ❑GRAVEL PACK/SIZE TYPE OF CAGMG/STEELfPVC DIA,OF WELL CASINO D C <br /> ❑ IC?AUNICIPAL ElOnIVEN DEPTH OF GROUT SEAL SPECIFICATION 5 1 <br /> IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E llllh��lll <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑Y- N. 5 \—V <br /> APPROX.DEPTH LOCKING CHESTEn BOX/BrOVE RPE S <br /> PROPOSED CONST9UCT10NIDPLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HERCnNIA.' <br /> TIFY THAT LAVE PREPARED THIS APMICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE.,MATE LAWS.AND RULES AN <br /> REGVDNS OF TIIE BAN OAOI COUNTY. NOME ER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF TIIE WORK FOR WIIICPL, <br /> THIS18 ISSUED.1 SII LL NOT EMPLOY RSO EJECT TO WORKMAN'6 COMPENSATION"WB OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FNG: 'I CERT THAT II F A CE OF FOR WHICH TR R=rr IS IS ED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMANY=OMMSATION"WS OF <br /> CALIF T T MVS 1 V CF FOR ALLRFOUPFD OM T ]OSI AAOJAtfCOMMUE DRAWING AT LOWER AREA DE"I.— Tl.e /1W/OE/ES{/VY Deb Y L// <br /> PLOT PLAN ID,.,.Beall Baeb__ jA6�� <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TIIE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSrEM On PbPO6E0 <br /> 1. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM.. <br /> 1 DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6, LOCATION OF WELLS WRHIN RADIUS OF ONE HUNDRED FIFTY <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS, AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY. <br /> �✓e l o ad <br /> \ 7vv\e- <br /> W <br /> PAYMENT 0}� LA <br /> �P <br /> CFIVED <br /> SEP 2 6 1997 <br /> SAN JOAQUIN UOUNTY <br /> PUFB-IC HEALTH SERVICES <br /> 'ENVIRCNME� L HEALTH DIVISION <br /> DEPARTMENT USE ONLY <br /> AppllaeSen A. WlBY / DN6 Aee <br /> D.le J <br /> OreuR Nnps,bn Br Punp Irnpee5en By _ _ _ D.R <br /> Ownue,bn Iwns,bn BY Deb <br /> Cnmmm,e: <br /> ACC ..H.Q ONLY: AIDE FACE <br /> PF CODES FEE INFO AMOUNT REMITTED CH CKAI ASN RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 0 h y c41-7 <br /> Pub.Health Sew.-Enviro.173(1197) <br />