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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 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TPIpffeet*) <br /> APE JCAT ION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMOR INSTALL THE WOR(DESCRIBED,THIS APPLICATION IB MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAP <br /> ITER 9-111[6.3 AND THE S AMANDA OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADOREBB/OR APNI �O/VFiII Pl-S4) '�S CITY PARCEL SIZUARII <br /> OWNER'S NAME 33 S-z o ADDRESS <br /> ` PHONE I <br /> COMRACpR � 9Pg/ClZ �o1 - PHONE 0 '2 <br /> I <br /> Ave CONTRACTOR ADDRESS UCE _PHONE I <br /> TYPE OF WELL/R1MP� ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONTORNG WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WEL <br /> L J <br /> S(/ ❑Naw❑R Ai' H.P. DEPTH PUMP SET�TT. FIRST WATER LEVEL 4T / 0 <br /> (TYPf OF PUMP) �,ty1�/�/ZIGC IPI F`O✓� <br /> /KI' ❑ OVT-OFBFRVICE WELL ❑ OEORIYSICAL WELL I ❑ BOIL BORNO B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> El INDUSTRIAL ❑OPEN SOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> DOMESTICRgVATE ❑GRAVEL PACKISIZE TYPE OF CASINOISTEELONC DIA,OF WELL CASINO D <br /> ❑ RISUC MUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL MECNICATION P <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY SNOUT AMNO NAME E <br /> ❑ MOMTORNO BENT REAL PUMPED: ❑Yr [IN. CONCRETE PEDESTAL BY DRILLER:❑Y. N. 5 <br /> APPROX.DFPEN � LOCKING CHESTER BOXISTOVE RPE 3 <br /> PROPOSED CONSTRUCTIOIUDO1LUNU MRIMD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS AR'ROCATION AND THAT THE WOR(WALL BE DONE m ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> SEOUILATIONB OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCFN9ED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT 18 ISSUED,1914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$DOMPNRSATION"We OF CALFOPMA_- CONTRACTOR'S HIRING OR BUS-CONT CTINO SIONATURE CERTIFIES <br /> THE FOLLOWIM 'I CERT( THAT R THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WDIUgN 4 'S COMPENSATION"WOOF <br /> CALJFORMA.' THIS MU/S�T CALL Z.1101111*IN ADVANCE FOR ALL REQUIRED INSFFC1�N1 AT IZOlH AHJMfe. COMPLETE DRAWING AT LOWER AREA "QEPD. v Q <br /> SIV—i X /1 I!J �-/ Tn. �.�C.Cl/f:/ <br /> PLOT RAN SN—I.MaI.I M.I. 1. <br /> 1. NAMES OF BTREETR OR ROADS NEAREST TO OR BOUNDING THE PIOPERTY. E. LOCATION OF HOUSE SEWAGE DIGOSM_SYSTEM OR PROPOSED <br /> Z. OUTLINE OF THE PROPERTY,01VI M DMENBIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE NOMBAL SYSTEMS. <br /> J. DIMENSIONED OUTIINF*IMO LOCATION OF ALL EXISTING ANO PROPOSED S. LOCATION OF WFLLB WITHIN MON*OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,ANO WAU(K ON THE PROPERTY OR ADJOINBIA PROPERTY. <br /> �D <br /> LT" �y <br /> v� <br /> LFA 1/'131 n - <br /> DEPARTMENT USE ONLY <br /> AP1IIM11—I A—. .l 8, Dw A,. <br /> 0'..In.pmflen er O.A. w'I.NI-0 n BraU 1 0.1. <br /> D.. Nn PwF..Abn Pv O.I. <br /> c aN" 99 O 5 I - C rT T r <br /> //- 2-9? * N $ SNI TJPR S B _ <br /> ACCOUNTING ONLY: AID/ FACT <br /> PE CODES FEE INFO AMOVNT REMITTED HECK/ ASH RECEIVED Sy DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 43 0 50 4;7 S' q l <br /> Pub Health So".-Enviro.173(1/97) <br />