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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ta —304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> I <br /> ROR•REFURDARtE PERRAIT EXPIRES T YEAR FROM DATE ISSUED <br /> ICompka In Triprketc) <br /> APPLICATION 18 HERE MY MADE TO THE SAN JOAGUIN COVNrY FOR A PERMIT TO CONSTRUCT ANDfOR W STALL THE WORK DFSCRSFO.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAOUIH COUNTY DEllELOAMEjR T'rL' CH ESR 9)-1116,3/RIND THE STANDARDS OF SAN JOAQUIN CnV/HtY PVBF,IC HEALTH SERVICER,ENNRONMENTAL HEALTH DINBION. <br /> JOS ADORES$/OR APNI �(JJ, !1J �A` V I CITY_A_'+/e!//•Y�/r PARCEL BIZFJAPN# q <br /> OWNER'S NAME I� I. /+ I ADDRESS J+ {. P`HyONE!— Z <br /> CONTRACTOR L 1R/�l�r ADDRESS C "LQA �_LC! <br /> I SUB CowwTOR // ADDRESS ilce p1/DNE <br />]� TYPE OF YYEU.IPUMPe QLPIfW WELL 13 REPLACEMENT WELL ❑MORROW"WELL P ❑OTHER <br /> I ,.,,. { Q INSTFA]LLATroN Q YELL SYSTEM AIR Q CFb89CONNECT REPAIR Q VAPOR FXTRACTfON WELL! <br /> \'F P1. ❑NSW 4.f i0.q�h H.P. OEM"RUMP SET_rr. FIRST WATER EEVEL D <br /> RYPE OF PUN% <br /> Q out-0FSEnwr wFLL ❑GEOPHYSCAL WETL! © SOIL BORNa a <br /> Q bteT'RvcrroN� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> 1❑,IH�DII$'RAL �❑O OTTOM /n DIA.OF WELL EXCAVATION c 1 DIA,OF CONOUClLl CA.— •�l O <br /> L�OOMESTCRRVATE L7 oMVEi.PACR/8RE `r TYPE OF CAMNOBTE"JPVC ..7 T�L' DIA.OF WELL CASMO w ,{ jl O <br /> Q RJRIJCUMUNICIPAL Q bnFAN DEPTH OF GROUT SEAL SPECIFK:ATON .i J L IF <br /> Q tR/YCIATbNfAG 11 OTHER GROUT REAL INSTALLEDBY GAOIR RRAND NAME '' .� E <br /> Q MONITORING Gnaw SEAL rF <br /> mmmo:yyw u Ns CONCRETE PEDESTAL BY DRImER:CL'p--❑Ne S <br /> APPROY.nF►TN LOCKMO CHESTEn SOXISTDVE FIFE <br /> FROPOSth CONSTRUCTIONMFULUNO METHOD' MUD ROTARY AIR ROTARY AUGER CASTE OTHER J <br /> 1 HEREBY CERttFY THAT 1 HAVE PREPARED TRS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,ANO RULES AND <br /> REGULATIONS OF THE BAN COUNTY.NOME OWNM On LICENSED AGENT'S SIGNATURE CERTSTES I'M POLLOWRTO!R CERTIFY THAT IN THE PERFORMANCE OF THE WORK rOR WHICH <br /> THIS PERMIT IS ISSUED,I IALL NOT PERSONS RUBJECT TO WORI MAN'S COMPENSATION LAWS OF CAUFOMA,'CONTRACTOR'S HIRNO OR SUR-CoNTRACThp SIGNATURE CERTIFIES <br /> THE FULL CE IFY THAT PERF ANCE OP TINE WOAR FOR ICH THIS 18 ISSUED,I BH/LLL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA T M 5 IN ASUVANCS FOR ALL REGURFD For;Iq,f{j8 COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> S1Pn.8 X TMh �T �ll F+` Dq, <br /> PLOT PLAN 0—n SpRRH e'er. 'to <br /> 1.NAMES OF STREETS OR RDADIP MEAREST TO OR 00111111300131tHE PROPERTY, 4.LOCATION OF ROUSE SEWAGE DISPOSAL SYSTEM DR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANMON OF SEWAGE D18POSAL SYSTEMS. <br /> 7.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING ANb PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCtUREN,INCLUDING COVERED AREAS SUCH AS PAMO.DRIVEWAYS,AND WALKS. ON THE rROPERTY OR ADJOINING PROPERTY. <br /> I <br /> t.... <br /> r 3` <br /> . 77Z p. <br /> . .J <br /> . .... . <br /> : . <br /> .... <br /> i <br /> I, <br /> OEPA.ME➢IT USE ONLY ,( <br /> APPS«IIa..AewElpd er "� D.. "' /! A, <br /> Grew 1mPmllrn <br /> by J '� L <br /> �f�'�-�6Z�/�.• L l�rdm /R.nah..PenlreRer_� '�4�d.>eC!,� DHH��i <br /> O«Inelbn Impw0m RY no. <br /> 4 <br /> it :f,r -_✓ %. a4�, <br /> i <br /> j ACCOURTINO ONLY: AIDS FACE (lYily ;(pdcI <br /> 1 <br />{ FE COOEe FEE INFO AMOUNT FtUMTTED HEC ASH AEC O MY DATjE PFIYAIIIEEAVGCF REG eT NUMSETR INVOICE <br /> Was <br /> 0-3 7t 12 yo <br /> 3'V 5'v 0 19 40S <br /> Pub Health Ser V.-EmAro.173(1197) , <br />