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r <br /> APPLICATION FOR WELL(PUMP PERMIT t.'l7 <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES 1�10 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 4683420 <br /> NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplate In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.��CHAPTTEERR/91115..3/w AND THE ANDAMS OF SAN JOAQUIN COUNTY PUBLIC HEALTH 6ERVICEB,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR 1APNI �V[/ /7�J�M�J'/D CITY,'r^ L/� /� PARCEL BIZEIAPN/ `�JJ l <br /> OWNER'S NAME <br /> /(1[J '�Q i'm C ADDRESS_A0400 /fi"4 e �E O ( ''7 PHONE 11&7- <br /> -Z <br /> ✓/-Dc+O Ol/ <br /> CONiMCTOfl_ e. 1 TK �C_a /,n (� S AODRF.66�D�Qx I"� -Z 1 UC/ Z 1 PHONE/4 <br /> BUS CONTRACTOR ADDRESS LSO/ PHONE <br /> TYPE OF WELLJPIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ Cross{ONNE T EPAIR ❑ VAPOR EXTRACTION WELL I J <br /> Tu.SGT e ❑Ne ❑R .I, H.P. 40 DEPTH PUMP SE <br /> RYP OF PIMPS T FIRST WATER LEVEL O <br /> El OUT-OF-SERVICE pWEELLL —/1J'❑ GEOPHYSICAL WELL/ El SOIL BORING a <br /> LgN:�Y1_ /N Q cc- fes- to?wV STN-' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/PW VATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA,OF WELL CASINO D <br /> ❑ PUBLICRUUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PIMPED: ❑Y- C1 N. CONCRETEPEDESTALBYDRILLER:❑Yr [IN. 5 <br /> APPROX.DF1TH LOCKING CHESTER BOX/STOVE PPE S <br /> PROPOSED CONSTRLICTIONIDEOWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERT THAT I"MiNFREPARED THIS APLATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> BEGULATK OF THE SAN JOA IN COUNTY. HOME O R LICENSED AGENT'S SIGNATURE CERTtF1E6 THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS R IS ISSUED,1 SHALL T EMPLOY PfFjSONSS0BJyCT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB{ONTRACTINO SIGNATURE CERTIFIES <br /> THE FO WING: 'I,CERTIFY OTHeNC THE WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION UWB OF <br /> CALIFO IA.' THE T UIAN FOR ALL REQUIRED AT I�tgB)4pJ 23 COMPLETE ORAWING AT LOWER OAMA PROVIDED. �/�J <br /> 61'n X _ U yW/^,Y(/ /iG(J ^iE_�T//^ )) / / <br /> pL �V <br /> PLOT RAN 0.le 6cY11 Sub 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OVTUNFS 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 WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> A10"'ode �C <br /> 1 �C <br /> G <br /> s <br /> b <br /> PLA <br /> JLL1 E: 1111 TI ,LLZ)/ILP <br /> 1 <br /> DEPARTMENT USE ONLY ,fEy r/E <br /> APPllullon Accepted BY \. 1>-J�V��/�//�/��y��a ' /yOFIa 1, • Aral A <br /> GreVl Impxtlpn BY Rla P p In,p.tbn BY T om/ �< �J Q-! �D�IV 7-q <br /> DsIrwtlen Impmibn BY Due <br /> Commemc <br /> ACCOUNTING ONLY: AID/ FACT <br /> -- _ FEE INFO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE PONIITISEAVICE REQUEST NUMBOR INVOICE <br /> J 035773 <br />