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y`G'L <br /> APPLICATION FOR WELLIPUMP PERMIT !�} <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES )fli�✓lp fcN Wu r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete In TTIplkele) <br /> APPIKATbN IS HERE BY MADE TO THE SAN JOAONN COUNTY FOR A PERIu1T TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TRtFf,CHAPTER 8-111 9.7 AND THE BTANOAADB OF BAN JOAOUPN COUNTY PUBLICO HEALTH CERVICES,ENVIRONMENTAL HEALTH LXVI <br /> JOB AODRFB�R �n ,(�,lL LLC JC) <br /> sr-'k CHY N w Y PARCEL <br /> OWNFR'B NAME !T• ���YI. L 1 ADONE88 ]�/� int 7-30" <br /> SUBCONTRACTOR 0 -r �+�/J� e'er ADDRESS 9-yN-,. X � -- UC/ 7-30 N (NONE) <br /> SUB CONTRACTOR +1 � f I/!a0 ADDRESS ! DCS�7Y PfeOi� %� z <br /> TYPE OF WUAJRIMP. ❑NEW WELL ❑REPLACEMENT WELL OTHER <br /> ❑y INSTALLATION [I WELL SYSTEM REPAIR 13C <br /> CROGGONNECT REPAIR ❑VAPOR EXTRACTION WELL/ J <br /> LJ"—L-1 Ilq k N.P. DEPT"RUMP SET—FT. FIRST WATER LEVEL O <br /> RYPE OF PUMP! <br /> - ❑OUT-OF-BEIIVICE WELL ❑OEOPHr6'ICAL WELL R 0 BOB.BORING g <br /> I �-1 <br /> o OEBTRUCTION: <br /> INTENDED USETP£�OF WELL CONSTRUCTION SPECIFICATION! r, A <br /> P 11INDUSTPoAI ❑OPEN BOTTOM G i DIA.OF WELL EXCAVATION .5 DIA,OF CONDUCTOR CASINO R O <br /> O DOMESTICAPRVATE GRAVEL PACKI.I E TYPE OF CASMOMTEEL/PVC�JfTrV LAA.OF WELL CA51NO eve— <br /> b <br /> ❑RURUCM NICIPAL ❑DRIVEN DEPTH OF OROUT SEAL a ��,, / SPECIFICATION a L�G p2 �R <br /> pp❑TT moo RONTAO ❑OTHER <br /> GROUT eEAL PNSYAUEb BY �Y^il �'I[ GROUT BRAND NAME t C • E <br /> Ea[MOTNTONNO n GROUT SEAL PUMPED:[3 Yw A- CONCRETE PEDESTAL BY DIIALER:❑Yw - 5 1 <br /> 1 rA—.-OEPFN b�✓ -. _-.. LOCKING CHESTER 8OX T! S <br /> PROTOem COMSTIVCTPNADNLLIna MFFNOO; MVD ROTARY_ l- AIR ROTAMKAUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1HAVE pRFPATEO TIRB APPLTCATMN AND THAT THE WOR(WILL BE GONE 1N ACCORDANCE 1NITH BAN JOAOIIIN COUNTY ORDINANCES.STATE LAWS.AND RI1LL8 AND <br /> REOIAATIONS OF TE BAN JOAQUIN COUNTY.HOME OWNER OR UCEN@ED AGENT-0 SIGNATURE CERFOrES THE FOLLOWLNO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WWCN <br /> THIS PEPoAIT IS ISSUEb,1814ALL NOT EYLR.DY PERSONS SUBJECT TO WORKMAN'S COMPMOATLON LAWS OFCAIIFORMA.'COMRACTOR'S WRIPM OR*U*-CONL RACTDIG SIGNATURE CERTIFIES <br /> TIRE FOLLOWING: .1 CFIRFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PFMNT IS ISSUED.1 SMALL EMPLOY PERSONS BURJFCT TO WOPKMAN'e COMPENSATION LAWS OF <br /> CAUFORHIA.' THE APPUCAM MUST CALL ND111U IN AwANCa FOR ALL REOU1Rm Ing"IcTIONS AT 12n 441040412.COMPLETE DRAWIINQ AT LOWER AREA RgNrD,EgO. (} <br /> jBRPrd X T. C-1 L7 O <br /> li PLOT PLAN ID,—I.O.NN a..I. t <br /> I.NAME@ OF 1111149 OR ROADS NEAREST TO OR BOVNDOM THE PROPERTY. 4.LOCATION OF—BE BEWAaE DISPOSAL BYBTEM OR ProPoSED �f <br /> E.OUTLINE OF THE PROPERTY.ORVBPG dMENeMNS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYBTEMB. <br /> SI <br /> S.DIMENONED 01"UNFPROPOSED,9 AND LOCATION OF ALL EXISTINO AND PROPOSED S.LOCATION OF WELL*WIT IN RAORUE OF ONE LRINDRED FIFTY FT. <br /> I IMICTLIREt INCLUDING COVERED AREAS SM"AS PATIOe,DRIVEWAYa AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY <br /> CIO cl <br /> �r�.. f/t1 LE L°�,nS7�l��fik � <br /> :. �ePTlznr9sl,-r' e <br /> . . <br /> PAYMENT. - <br /> ... <br /> MAY 9-8; <br /> Z ? 51o`r <br /> :. <br /> SG-ble.�.46rn <br /> VC_. ' SAN,fUAG1UINCOII�v <br /> PI3FSi1C HF1,LT}i SERVI E5 - <br /> ENVIR <br /> ' r bT)MTMPPT USE ONLY '�+ <br />{ APPE..R.n^—W d BY O 6 <br /> OIauI Irwae.Ban Dr D.I. �^ '; go Rms IrnPa.Rhn Br DM. <br /> OeNnIellen Irra.�Pwl Br Dn. <br /> t.ala,ere.: <br /> r� ACCOUNTINOONLY: Alb/ FAC/ <br /> 4 FE CODES FEE INFO AMOUNT REMITTED CIIEC ICABH RECEIVED BY DATE P9INTISUMCE RLEOUFST NLIINSBI INVOICE <br /> 12-0 0. Ero <br /> 1 <br /> I <br />