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�tl� APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br /> (209) 408.3420 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Tr(Plleelel <br /> APPLICATION 19 HERE By MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOn INSTALL THE WORK DESCRIBED.T11I8 APPLICATION IS MADE IN COMPIANCE VJr1118AN <br /> JOAQUIN COUNTY DEVELO��TITLE.CIIAPT 8-11 TD,3 AND TII BTA gA}1p9 OFi 9AN JOAQUIN COUNTY FUBpC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSMR APN'_ I JOE-)� /YL(� I Il-` '�I/Iff`Jf'-'.'' <br /> A p ^ y�CIT-1 PARCEL BIZEIAPNI I V <br /> OWNER'8 NAME_ 11W�'� l�"L1"-� f ADORERS <br /> C/ �yPONEE /ZJp — /L7�1�G�� <br /> CONTRACTOR �C L L /J�I I I`� ADDRESS(�/.JI�OFJ LICKS -TI 1� NE E YVb TITS. ) <br /> sue CONTRACTOR ADDRESS �� �/ 1 iO <br /> ¢ <br /> UC' �PHONE I <br /> TYPE OF WELIJPUMP: N WELL ❑ REPLACEMENT WELL MONITORING WELL I 1 —�j ❑ OTHER <br /> 1�1 TALLATION ❑ WELL SYSTEM REPAIR ❑ CROBB-CONNECT REPAIR ❑ VAPO-EXTMCTION WELL <br /> L�New❑Rep.Ir ".P. DEPTH PIMP SET <br /> DYPE OF PIMP FT, FIRST WATER REVEL p <br /> _ <br /> ❑ OVT OR SERVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ SOIL BONITO R <br /> ❑DFSTRUCTIO W - <br /> INTENDED UEE TYPE OF WELL COfigRUCIION EPECIfICAiIONe ..��Et A <br /> ❑ INDUBIRIAL ❑�,,O�PENBOTTOM �1 CIA.OF WELL EXCAVATION I DIA,OF CONDUCTOR CAGING I D <br /> 11D0ME9TICIPIVATE L'JLiiRAVEL PACKIBIZE ` 'Z TYPE Of CASINOIGTEELIPVC DIA.Of WELL CASINO 2 1 0 <br /> ❑ PIBLICIMUN1CmAL ❑DRIVEN DEPTH OF GROVE SEAL SPECIFICATION R <br /> ❑ IRj110ATIONIAG ❑OTHER ,E – GROUT SEAL INSTALLED BYE— GROUT BRAND NAMF <br /> MONITORING _ �.E1.� GROUT SEAL PUMPO: [3Voe L_TNe CONCRETE PEDESTAL BYOPLLER: Vw []No S <br /> APPROX.DEPTH_ ! lT•,I`–n��11Y LOCKING CHESTER BOX/BTOVE PIP S <br /> PROPOSED CONSTAUCTIONIDRILUNG METINID: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY TIHAT I HAVE PREPARED THIS APPLICATON AND THATOEW LL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND MUG ANO <br /> REOULATIO OFT 8AN JO UIN COUNTYIIOM ER LICENT'S SIGNATURE CERTIFIES THE FOLLOWING:'ICERTIFYTHAT INTHE PERFORMANCEOfTHEWORK FORWHICH <br /> PnM1IB ISBUISHAt OT PLOY PEP NB BV JEC TO WOC0 PENeAT10M UWS Oi CALIFORNIA.' COMRACTOR'B IIWNG DR BUBLOMRACTING 61GNATUPE CERTIFIER <br /> lO NGIAT 1 IIF PE ORMANC OF HE WOn THIS PRMTT IB ISSUED.1 SHALL PLOT PERSONS SUBJECT TO WORXAIAN'S COMPENSATION LAWS OF <br /> THEA T CA ] WS IN ADVA CE FOR ED INEFFCTIONNA AT 1]M) JI . COMPLETTEGNAWINGATLLOWER AREA PROVIDE l. �L r H/I` • y � Dela ) u 7/ <br /> lu <br /> ROT N Im—le%w.I Raeln I Re({{JO <br /> T. NAMES OF BTREETB OR GOADS GI NEAREST GI OR BOUNDINAND NO THE IWCTION. t. LOCATION OF HOUSE SEWAGE AL GYRTL SYSTEM 00 MOPOSED <br /> S. OUTLINE OF TIO POPES AN LOCA DIMENSIONS AND IN H DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> ]. DIMENSTRUCT nis. OUTLINES AND LOCATION OF ALL AS PATO AND FflO�DRIVEWED <br /> AYS, <br /> e. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED TIFTY fT. <br /> STRUCTVREB,INCLUDING COVERED AREAE SUCH AS PATIOS,DRIVEWAYS,AND WAlXB. ON THE POPEnrY On ADJOINING POPENTIY <br /> r ^ ' <br /> 'v <br /> ZIA <br /> f LuGah„ <br /> F4Li <br /> I <br /> DEPARTMENT USE ONLY <br /> APPlleeleR Aeamlp 9Y Det. V D MeeI//,Vw <br /> 0'..lwpeeree Br Poo W Penp Inepennen By D.I. <br /> OwmnUen lmr/eenen 0, D.I.J <br /> CemmNN.: �I ^� � ��/.� V/ �.G .y" �.L� /J✓L�O(r��]XL�L 1/.<C/tM.t�^ �S <br /> ACCOUNTING ONLY: AID' TACE <br /> PE CODES FEEIHFO AMOUNT EMMETT ED IEC /CA$N RECEIVED BY DATJE PFNMITISERVICE REQUEST NUMBER INVOI[F <br /> Pub.Health SIGN.-Enviro.173(3/96) <br />