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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 95201388 <br /> 1299) 4663420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete I { <br /> APPLICATION IS I4EM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT S <br /> ANOMA IN <br /> UNTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMRANCE WRFH SAN <br /> JOAOUIN COUN DEVELOPMIW TITLE,CHAPTER S-1116 AND THE STANDAR OF SAN JOAQUIN COUNTY RBOC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMBON. <br /> JOB ADDRESSOR AR/ O DEA„ <br /> DY1 �0. JAREL SIZVARI <br /> OWNER'S NAME ADDRESS OI SQ{.L <br /> 1F`IONE t <br /> CONTRACTOR ADDRESS 11CI /lam„ 466-162,5 <br /> ONE F <br /> BUB COMPACTOR ADDRESS IJCE <br /> PHONE <br /> ` TYPE OF WELUMIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL E ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT kPAIR ❑ VAPOR EXTRACTION WELL�I J `� <br /> 11 llv13 eel, M.P._ r DEPTH RMP SET FT, FIRST WATER LEVEL �J O <br /> FOYLE OF PUMP) p <br /> p❑ OVTAF-BEII/V�ICE WELL ,1❑1 GEOPHYSICAL WELL A ❑ SOR RnING S <br /> WFYiAtlBi10N:�L.1n��_-_y.t L`. A�✓1 • - )( <br /> INTENDED U E TYPE OF WELL ON{TRU 1 N SPECIM ATION{ A V <br /> ❑ IN=RIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p <br /> ,LTJ•/�MESTICTRIVATE ❑DRAWL PACKIBNf TYPE OF CASINOISTEEVPVC DIA.OF WELL CASINO p� <br /> ❑ RBUCJMUNICIPAL ❑DnWEN DEPT"OF GREW BEAT SPECIFICATION R <br /> ❑ IRRIGATIONIAG ❑OTHER GREW SEAL INSTALLED BV GRIT BMW NAME F <br /> ❑ MONITORING GRIT SEAL RMPEO: ❑Yw [IN. CONCRETE PEDESTAL BYDnOJER:❑Yr [IN. 5 <br /> APPROX.DEPTH LOCKING CHESTER R%IBTUVE MPE S <br /> PROPOSED CON{TRMITON/DRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9ERY CERTIFY TH )AVE MTE RED THIS APMJCATION AND THAT THE WORK WILL BE DOME IN ACCORDANCE WITH BAN JOA <br /> OVIN COUNTY ORDINANCES,STATE UWe,All RUIEe All <br /> nEOIMTON9 OF E BAN JOAOVIN UNTY. HOME OWNER OR LO NSM AGENT'S BONATURE CERTIFIES THE FOLLOWING:"1 CERTIFY THAT IN THE KWORMMCE OF THE WORK FOR WHICH <br /> THIS PEnMIT M SLND,1 WALL RT M ELY PERSONS SUBJECT ORKMAN'{COMPENSATION LAWS OF CALIFOROA." CONTRACTOR'S MNNO OR SUBCOMRACTMO BONATURE CERTBR6 C� <br /> THE FOLLOW) "1 CE IFY T TIIE FE ORM F M FOR WHIOH T RRI.IR IB 1{SUED,1 WALL EMPLOY PERSONS SUBJECT TO WORIOAAM't COMFFNMION LAWS OF <br /> CALIFORNIA: THE A MU CALL NO FOR W 1 TON{//Ij/}/'�2MI/4{{�-1 22. COMPLETE DRAWING AT LOWER AREA Pfm O . xq O <br /> fa,,e x TBIe _V W /.w./Y Deb_/O /U — /" (� <br /> ROT MN 0.le eeelel SCNe "to a <br /> t. NAMES OF BTREFTS OR RADS NEAREST TO OR BOUNDING THE PROPERTY. �. LOCATION OF RUBE SEWAGE DISPOSAL SYSTEM OR PRITISED <br /> 2. OUTLINE OF THE PROPERTY,OMND DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLMEB AND LOCATION OF ALL EXISTING AND PROPOSED E. 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 /> Y. <br /> �WITwe e�dRd <br /> 9 d 2d . <br /> n,; Y <br />