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APPLICATION FOR WELLIPUMP PERIV"\ 00 bar <br /> SA. JOAQUIN COUNTY PUBLIC HEALTH SE. ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) "B-3420 <br /> NON•REFURDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (C4mpl6t6 In TrIpRa616) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAGUIN COUNTY DEVELOPMENT <br /> /TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOBAbORESSIORAPN# I%I =/ /77/rJY+✓' PARCEL BIZFJ <br /> OWNER'S NAME /� ADDRESS <br /> CONTRACTOR / ADDRESS lif. / 'f2[(�C iUCf��3�/ , PHONE I <br /> SUBCONTRACTOR ADDRESS ,„�,f" UCI - PHONEI <br /> TYPE-OF WELL"mp,, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLO ❑ OTHER <br /> ��+ ❑ INSTALLATION C] WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J �— <br /> f (AN.❑Repdr H.P. _ DEPTH PUMP SET_&d_FT. FIRST WATER LEVEL_ <br /> (TYPE OF PUMP) ' <br /> ❑ out-or•BEnvicE WELL ❑ OEOPHYsICAL WELL I ❑ SOIL BORING S <br /> ❑DESTRUCTK)N: U' <br /> IMTENDED USE TYPE OF WELL CON6TRUCtI0' <br /> N SPECIFICATIONS - ,y <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM OtA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO p <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ mmaATIONIAG ❑Otmn GROUT SEAL INSTALLED BY GROUT BRAND NAME g <br /> MO -S <br /> ❑ NRORIMO GROUT SEAL PUMPED: ❑Yo. ❑He CONCRETE PEDESTAL BY bRILLEq:CJ Yw ❑Ne S <br /> APPROX.DEPTH LOCKING CHEBTER BOX/STOVE pipe <br /> PROPOSED CONSTRUCTIONRNtlWNO METHOD: MUD ROTARY AIR ROTARY AVOER CABLE OTHER_-.. <br /> I HMRY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TIIE WORK FOR WHICH <br /> THIS PERMIT M ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPERGATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONFRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS rEFtMnr 19 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORNIA.' T CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS At 12441 4643423, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Slpned X TISe <br /> PLOT PLAN Mtew to 4edel Bode •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,DIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> S. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDMO FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ;,. .. . .. ... <br /> R <br /> .. PR.;.. 4.1998... <br /> P qry . <br /> itdt ri'NPv; r' ..L FiIH LTH D114v )m <br /> P� <br /> y <br /> r }� <br /> DEPART1V"RMYUlIlt LY-;�.T... <br /> 3 <br /> Applledlen Aoeepltd By Dote Arw <br /> Grein"osallen By Date PR p hnpoctten'By Date .J <br /> Oeetomtlon Impeotlen By Det. <br /> Ceinmm�le: f'3 `j C 1 S - C( Lr - <br /> ACCOUNTING ONLY: AID# PACO <br /> PE Coon FEE INFO AMOUNT REMITTED CHE K (CASH RECEIVED BY DATE POWITI61FIVICE REQUEST"mom INVOICE <br /> a e510 '5 a 1 <br /> Pub.Health Serv.•Enviro.173(1/97) <br />