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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NDN-REiUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TrlpReRISI <br /> Ar"-ICATION IR IIFRE BY MADE TO TIIE RAN JOAOUIN COUNTY FOR A PETUAIT TO CONSTRUCT AND/On INSTALL 1UF WORK oESCRIRED.T1119 APPLICATION IB MADE IN COM <br /> JOAOIIIN COUNTY bE VEI OPMENT TTTLE,CIIAP7ER 9-1115.3 AND TIIE 8TANOAnO9 or BAN JOAOIIIN COUNTY PUBLIC IIFALTII SFRVICER,FNVUIONMfTLIAIICF WITH BAN <br /> I11 AL IIFAL111 DIVISIONrn <br /> JoltAnonERRA3n APHI � 01r7 M 6 S"r,-/j e CITY / <br /> _ CA rn 0 PARCEL RIZE/AMJI_ I �1 <br /> ONTTER'R NAME ><1C rL.lh ,p 7{7Ls1'L ADDRESS S <br /> } [jt t' r'110NE/ 3 6k- /T a S' <br /> CONTnAclon ��1–w /�F2��S n Aor)nFRR Iry G'j 11 k Loco 773 �'S n1oNE I 3/ - (., . -F <br /> AV"CON7 RACY On 6, `ai r2l 9u ADDnERR C2A�7 LIC• <br /> / PHONE <br /> TYPE OF WELL"MP; Y3.p�NFW WELL ❑ nFPt-ACEMENT WFLI ❑ MONITORINO WELL I ❑ OTIIFn <br /> h ❑ INSTALLATION ❑ WELL RYRTEM nEPAIn ❑ CROPS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> DEP1H PUMP RET FT. fInBT WATER LEVEL <br /> -� 1 <br /> RYPE Of PIIMPI -- <br /> ❑❑ <br /> DFaTRVC7ION! OUT-or RFRVtCE WELL ❑ GEOPHYSICAL WELL I ElSOIL BORING <br /> f- <br /> INTENDED Use TYPE OF WELL CONSTRVC110N SPECIFICATIONS \ <br /> ❑ INDVRTRIAL ❑Or'EN BOTTOM DIA.OF WELL EXCAVATION Z <br /> DIA.OF CONDUCTOR CASINO <br /> J;�TgMD <br /> FSI1C"IVATE AROnAVFL PACK/BI7F TYPE OF CARINO/RTEELIPVC ( ✓ GIA.Of WELL CASINO <br /> ❑ Punv ic/MVNICIPAL ❑OMVFN <br /> DEPiN OF OROIR SEAL I (7k-) BPfCIfICAT10N <br /> ❑ Inn10ATION/AO ❑OTUFn OnOUT REAL INBTALLED BY CJ/...�}l.❑ G110UT BRAND NAME_ C�,�'YI C'/-.j <br /> E MONITORING REAL PRIMPED: ❑Yw ❑Ne CONCnV E PEOFBT AL BY DMLLER:❑Y.. ❑Ne S j <br /> APPnOX.DEPTH LOCKINO CNEBTEn BOX/91OVE PIPE <br /> PTIOPORED CONSTRUCTION/OERt.LINO MFTII00: MVO ROTARY X Ain nOTARY AUGERCARLE OIIIFR <D <br /> I IIEnERY CEnTIrY THAT I IIAVF.PFIEPARFO 71119 Al"I'MATION AND THAT THE WOW WILL RE DONE IN ACCORDANCE WITH RAN JOAQUIN COUNTY OnO1NANCER,STATE IAWR,AND RULER ANO�F <br /> nEO1PLATIONR OF 111E RAN JOAQUIN COUNTY, NOME OWNEn On LICENSED AnENT'R RIONATUnE CFFNIr1ER TIIE rOLLOWINO: 'I CERTIFY 7IIAT IN THE PFRronMANCE Or TIIE WORK fon WIIICIL I <br /> TIIIR PERMIT OR ISSUED,1 RANI l NOT EMPLOY PIFARONR SUBJECT TO WORKMAN'S COMPENSATION U1WR or CALIFORNIA.' CONTRACTOR'll(AMNO OR PUN CO <br /> RIONATUMF.CERTIrIF1111[`+�� <br /> TItE rO1.LOWINO: '1 CERTIFY THAT IN TIIE PF.nrOnF.IANI'E OF TIIE WOnK POR\MUHCTIIIR PfnMrT IR IBRUEn,1 @HALL EMPLOY PEnRONR RURJECT TO WORKMAN'SCOMPFNRATION LAW.Orr <br /> CAI.Ir OnNIA.' THE <br /> /APPLICANT FAUST CALL 24/IOVn/IN ADVANCE FOR ALL REOUInFO INSPECTIONS AT 120e1 Ree-3422, COMPLETE DRAWING AT LOWEn AREA PTIOVtDFn. <br /> Rlpr.wAX / �A% Till• OCA, Aj'L._. <br /> PLOT PLAN It),—to 19-1.3 Re.I. le <br /> 1. NAMFR or 9TnFETR On ROADS NFARFRT TO On BOUNDING 111E PTIOPERTY. 4. LOCATION or MOVIE RFWAGF DIRPOBAL BYRTEM On PM)rO8[n <br /> 7. OUTLINE OF TItF 111OPEFRY,ann"a DIMENBION8 AND NORTH OInFC7ION. EXPANSION OF.FVVAnE DISPOSAL RYRIFMR. <br /> 3. DIMFNAIONFO OUTLINFR AND LOCATION Of ALL EXISTING AND PnO/ORF.O E. LOCATION Of WFILe Wrt"IN RAdue OF ONE HUNmmn FIFTY ri. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AB PA7108,DMVEWAY8,AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY. <br /> rh t S 7'E�aD <br /> CfTI+� <br /> NO <br /> F�A <br /> I ; <br /> Y <br /> ' MEN(' <br /> I CT 0 2 1997 <br /> PUBLIC HEALTH SERVICES <br /> DEPARTMENT USE ONLY ENVIRONMENTAL.HEALTH DIVISIO� <br /> Abnlluann Aenrolwd By <br /> Owl. CJ ✓• A,�w <br /> GroiA Imbentbn BY Oaw( - L P—P Imbeetlen By:!_ /���� /A _,/ D.1•�(�_` (�_�f. <br /> b+.b�.ntle..Irnnw,:lbn <br /> By rl <br /> C,nmmwr.t <br /> ACCOUNTINO ONLY: NIDI TACO <br /> PE CODER FEE INTO AMOUNT REMITito CIIECKI ABI. 1 RECEIVED BY DATE PERMIT/SEIIVICE REOUEST NUTAPM INVOICE <br /> .O6O <br /> U-13 E <br /> Q 5 oy 135 <br /> Pub.Health Serv.-Enviro.173(1/97) <br />