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APPLICATION FOR INELLIPUMP PERMIT v Oo 2-oz7 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �G� :2, <br /> b 215 <br /> ENVIRONMENTAL HEALTH 01VISION7 <br /> P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (2091461-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> [Complete In TripREBleI <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WOPK DESCRIMO.TIDE APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TIME,CHAPTER 5-1115..33 SAND THE STANDARDS Of BAN ?0AGUIN COUNTY%//{B�UCf�N,,E♦AL,TII BERVN:EB.ENVIIIONMEMAL HEALTH DINBIOV O <br /> JOB ADOMIUMR APNE I S 37 �I,�/�� ' •�E/ CTf �,(`y�/FA'�iAN�� PAIICEL SIMAPNO /V^J� <br /> OWNER'S NAME � L-7- <br /> /// I/=,Lam) S C A ADDRESS -S,, /qi�//IL^�"6 E y WNE/ SSV -Z S3 <br /> CONTRACTOR ��/JJ ^ Gas sr AODRESS_JS eJOfl [ / O UCIJ77)0r <br /> BUB CONTRACTOR_ ( ?o('T (/ell,, (/hAP's ADDI1E68 (']A G7 UCE PHONE/ <br /> TYPE OF WEUJPUMP: .OL,NEW WELL ❑ REPLACEMENT WELL ❑ MONITORNO WELL/ ❑ OTHER <br /> INSTALLATION 11WELL SYSTEM REPAIR ❑ CROBS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ <br /> SL/c New❑Repel, T H.P. DEPTHRIMPSET FT. FIRST WATER LEVEL O �J- <br /> NYPE OF PIMP) <br /> ❑ OUT-0P SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ BOR BORING S <br /> Qr <br /> ❑DESTRUCTION: LV!1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �1 A <br /> ❑ INDUSTRIAL 0rt3. EUOPEN BOTTOM CIA.OF WELL EXCAVATION V DIA.OF CONDUCTOR CAB p <br /> �OOME!UICMIBVATE .IaLGRAM PACKME TYPE OF CASIMANCPVC DIAOE WELL CASING p - <br /> ❑ PIBLICIMUNICIPAL ❑DRVEH DEPFN OF GROUT REAL /O/D� ' n SPECIFICATION <br /> - ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED <br /> 6BY�� \.,AAi'f(� GROUT BRAND NAME t/� E <br /> ❑ MONITOnl" y- GROUT SEAL PUMPED: E Y. 0 N CONCRETE PEDESTAL BY DRILLER: ❑Ne S <br /> APPROX.DFrTH Z O L LOCKING CHESTER BOXIBTOW RPE <br /> 5 <br /> r. <br /> PROPOSED CONSTIIUCTIONIDRIWMO METHOD: MUD ROTARY-�_AIR PATARY AUGER CARIE OTHER'- <br /> 1 HEREBY CENTHY THAT I HAVE PREPARED THIS AP ILWATION ANO THAT THE WORK WALL BE DONE IN ACCORDANCE WITH BAN MAWR COUNTY ORDINANCES,STATE LAWS,AND Wife ANO <br /> REGULATIONS Of THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF DIE WOW FOR WHICH <br /> THIS PERMIT It ISSUED,I SUALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSADON LAWS OF CALIFORNIA.- CONFIRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLO'MNG: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 MSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WONXMANY OONIMMAT10N LAWS OF <br /> '- CAUFORMA.' THE PUCAN MUST C,ALL/ M HOURS IN ADVANCE FOR ALL REQUIRED INSPECDOH I AT <br /> (120114q JEPROVIDED. <br /> TS. COMPLETE DRAWING AT LOWER AREA <br /> BIOeeM X / / DLI. <br /> MOT RAN Bit.Ie S W.j S Ww 'to <br /> 1. NAMES OF BTREFT8 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE OISPoBAL SYSTEM OR f1OPoSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION Of SEWAGE DISPOSAL SYSTEMS. <br /> B. DIMENSIONED OUTLINES AND LOCATION Of ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDIIEO FIFTY R. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPHTFY. <br /> x/0 C/ <br /> 1 <br />