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i7 <br /> APPLICA' ON FOR WELL�PUMP PERMIT <br /> L SAN JOAOUIN COUR!Ty PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL,HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> c�"''w ;209) 465-3420 <br /> Lai NON-REFUNDABLE PERMIT EXPIRES 4 YEAR FROM DATE ISSUED <br /> ICnmPlate in T►fpPeata) <br /> APPLICATION 19 HFRE BY MADE TO THE SAN JOAQUIN COUNTY FOP,A PERMIT TO CONSTRUCT AND/OR.INSTALL THE WORK DESCRIBED.Ti11S APPLICATION IS MADE IH COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 115.3 AND THE STANOARO9 OF CAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> no JOB ADDRESS/OP,APNB�'t <br /> 1..J�C� CITY 1 ll` <br /> / PARCEL SIZFfAPNa �\ <br /> OWNER'S NAME Cl '� 1/% !:_.k- ADDRESS r <br /> ..g i? ::. . .� r,.1 <br /> /1 Y PHONE I. .!_3 1 J U <br /> COW" <br /> croq E A d--A !" � 1`i 'i� �DOREae CJ l b },_ `�i�^,C j (� �:/�.• <br /> PHONE <br /> Eve COFTTMCTOR �'L tali ��,� .. A 1 i J p� � ADDRESS <br /> f IJC# PHONE I< <br /> TYPE OF WELL/PUMPi NEW WELL ❑ REPLACEMENT WELL PJ MONFTORING WELL A ❑ OTHER <br /> gyp❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRO35 ONNECT REPAIA Cl VAPOR EXTRACTION WELL a_ <br /> y-c�1 Ns ❑11ep.1, H.P. 10 DEPTH PUMP SET FT. FIRST WATER LEVEL J <br /> (TYPE OF PUMP) 0 <br /> Cl WELL ❑ GEOPHYSICAL WELL a ElSOIL BORING S <br /> El DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> El .c A <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION T DIA.OF CONDUCTOR CASING 0 <br /> L ,f OOME9TIC/MVATS AIRAVEL PACK/91ZE TYPE OF CASINO/6TEEVPVC r- DIA.OF WELL CASING <br /> ElPVBLICIMUNICIPAL DRIVEN DEPTH OF GROUT SEAL to cr,-1 L1 SPECIFICATION <br /> IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY—r-C 1l,7P i.t'/L_ GROUT BRAND NAME �', laY�^z' E <br /> ❑ MONITORINGGROUTSFALPVMPEDYos He• ❑ <br /> � CONCRETE PEDESTAL aY OFUIlER: Yee [3N. ,S <br /> No <br /> APPROX.DEPTH_ / yLOCKING CHEtrTE!i BOR/STOVE PIPE S <br /> PROPOSED CONBTRUC TIO NRIRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND FI AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIEC THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTMCTOR'a HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CELT IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENOATON LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOLR40 IN ADVANCE FOR ALL REGUMED INS►BCTIONS AT 1211®)4444.-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed X ' / <br /> o ��r` � �t'--= True-�i.R/ff..-�!=� D.t®� �,"U � l <br /> PLOT PLAN 9),+ to Sole)Soele 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,O1VVM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTFMS. <br /> 1, DIMENSIONED OUTLINES AND LOCATION OF ALL EXIST"AND PROPOSED S. LOCATION OF WELLS WPTNIN MONS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR AOJOINWO PROPERTY. <br /> P <br /> L <br /> d <br /> X �A d- (� <br /> Lii V4'1Rr r;, i iYtL.E5 <br />