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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 95201388 <br /> (209) 4583420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Compltm in Tripfmm) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAWIN COUNTY FOR A PER UT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> "AWN COUNTY OEWLOPI E TfRE,CHAPTER 9-1119.3 THE STANDARDS OF SAN JOAQUIN COUNTY WSUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRE891On APWU C� CRY PARCEL SDEJARN# <br /> W <br /> ONER'SNAME Ka.rI0. LS ADDRESS I RIONEI g <br /> CONTRACTOR b ADDRESS MO PHONE It <br /> SUS CONTRACTOR ADDRESS LIC# RHONE 0 <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL It ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR3cCROSS{ONNECT REPAIR ❑ VAPOR EIO <br /> XTRACTN WELL• J <br /> ❑Nqv H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O <br /> RYPE OF RIMP1 r AQ <br /> CROSS oN/V ❑ O?UT-OF-SEAVIOE WELL ❑ GEOPHYSICAL WELL#T'•'� ❑ sImE/wRNO B <br /> DESTRUCTION G C I /D/, R G T)ti I R. — /� i'Ya�� /GH:/� MiN <br /> n. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> ❑ INDUSTRIA) ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O <br /> ❑ DOMESTICITRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/6TEElNJC DIA.OF WELL CASING D <br /> ❑ <br /> MSM/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> rIIRRGATION/AG ❑OTHER GflOUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED:❑Y. ❑No CONCRETE PEDESTAL BY DRILLER:❑Ys ❑N. 5 <br /> APPROX.DEPTH LOCKING CHESTER SOX/6TOW RPE 5 <br /> RtOPOSED CONSTRUCTION/URIWNQ METHOD: MUD ROTARY AIR ROTARY AIOFA CABLE OTHER �1 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS ARLLATION AND THAT THE ihOW HALL SE DONE IN ACCORDANCE WRH SAN JOAWIN COUNTY ORDINANCES,STATE LAWS,AND RUEE6 ANO <br /> IHEGULATIONS OF THE SAN tOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR"ICH <br /> THIS PEANUT 16 ISSUED,I SHALL NOT EMPLOYPEflSONS T TO WORIQIAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUSLONTRACTING SIONATURE CERTIFIES <br /> THE FOLLOWING: 1 CERTIFY T TIN THE PERFO O THE MW FOR WHICH THIS PERNIET IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> C FOPNIA.' T US C\NO ONCE FOR ALL REQUIRED INSPEC W/ IMH lJtl AT 23. COMPLETE DRAWING AT LOWER AREA PRO DE. <br /> 61gM X ` Title D.I. <br /> PLOT RAN IO—to S.MeI bub 'Ie <br /> 1. NAMES OF SEPEETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WRHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WAlX6. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> Ip . <br /> s <br /> LJ <br /> V <br /> JUN ] 13?5 <br /> ` � 3/ `I. /,f' Gan1 Inannanl rnl nil v <br />