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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 V <br /> NONREFUNDABLE PERMIT EXPIRE9 1 YEAR FROM DATE ISSUED <br /> (Complain In TLipHents) <br /> AF ICATION 19 DERE BY MAGE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANpgR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE MD SAN <br /> JOAOUIN COUNTY DEVELOPMENT(/TITLE,CHAPTER 9 11//115.]'/S�N,D THE"ADAgDB OF BAN JOAQUIN COUNTY RIBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH OMSIaOH.z <br /> JOB ADDRE89gR APNI SU(N7/L �-c/�� J�-(,/l CITY(' /•/�� <br /> oh -EL SIZEJAPNE_�(` -3zy� <br /> OWNER'S NAME ///V �Gi/YGI ADDRESS /Z/V �I/7C�-Ily /'tir_Cn/TL/ C RbRE/ 7Yl� OS/J ' <br /> CONTRACTOR Q � ADDRF88 LICE PHONE 0- <br /> MAS CONTRACTOR ADDRESS LIC/ PONE I <br /> TYPE Of WELLIPIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL E ❑ OTHER <br /> -Wa p O� ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR El VAPOR EXTRACTION WELL <br /> AANG ❑N—cl H.P DEPTH PIMP EST_". FIRST WATER LEVEL O <br /> RYTT OF PUMP, ���...yyy <br /> yOUT-0F SERVICE WELL 11OEOMYSICAL WELL I ❑ SOIL BORING B <br /> 11 DESTRUCTION' <br /> /, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS nn'�11/! A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION V DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTICR VATS ❑DRAWL PACIISIIE TYPE OF CASIMMTEEVPVC DNA.OF WELL CASINO O <br /> ❑ PLAIM MUNICI`AL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> IRRIOATONIAG ❑OTHER GRO FF SEAL INSTALLED BY GROUT BRAND NAME F <br /> MONITORING L,� v ,. GROUT SEAL PIMPED: ❑Y.. [IN. CONCRETE PEDESTAL BY DRILLER:❑Y. [IN. S <br /> APPROX.DFJRH UG kAco LDCXINO CHESTER BOXISTOVE RPE ,S <br /> PROPOSED CONSTRUCTION( LINO METHOD: MUD ROTARY AIR ROTARY AUOEfl CABLE OTHER <br /> I NEWBY CERTIFY THAT I HAVE PREPARED THIS A ATMN ANO THAT THE WOK WILL BE DONE M ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,I MNALL NOT EMPLOY PERSONS SUBJECT TO WORXMAN'n COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR 9 LOPING OR SUBCONTRACTING MINIATURE CERTIFIES <br /> TDE FOLLOWING' 'I CERTIFY T M THE PERFORMANCE OF THE WORK FOR WHICH THIS PEMD'18 ISSUED.I SHALL EMPOY PERSONS BURJECT TO WORIOAAN'S COMPENSATION LAWS OF <br /> - CAL TORNIA.• THE ANUG MRMT CALL S.MURn iN ADVANCE FOR ALL REQUIRED INSPECTIONS AT IEOSI ASniEPRE <br /> tn. COMPETE DRAWING AT LOWER AA PRO OFD.9 <br /> Bl.d X l -�i' -- � Till. �(''"/L'�ir D.1. �/t (!/+ <br /> KOT PLAN ON—R.BPr.I&.I.�•Le� <br /> 1, NAMES Of STREETS OR ROADS NEAREST TO OR POUNDIM THE POVERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> T. OIrt(INE OF THE PROPERTY,OIVIp DIMENBONS AND NORTH DRFCTION. EXPANSION OF SEWAGE D9FOSAE SYSTEMS. <br /> J. DRMENIMNED OUFLINFB ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WDN1N RADIOS OF ONE NUMMO FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS RATIOS,DRIVEWAYS,AIA WALKS. ON THE PROPERTY OR ADJOINIO PROPERTY. <br /> ' ` _ A <br /> AINP YINAE 3 ( <br /> :zz- C7 APS 3 0 9998 <br /> O b N TP-94(*j'EN veil ss rs1�rY�p <br /> N� f L1E1LI f fl <br /> J &lur1MHEALTH <br /> ALDNI( <br /> IZS���• � IEMT/uHEALTHDSWSIFjH <br /> � a� �ervlC.c <br /> ti <br />