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t <br /> ENT-' <br /> VED, <br /> APPLICATION FOR WELLJPUMP PE IT(CPSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 2''S 2000 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON CA 95202 SAN JOAQUIN COUNTY <br /> I PUBLIC C HHEEALTH SERVICES <br /> (209) 468-3420 ENNRONMENTAL HEALTH DIVISI ) <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �f (Complete In MplkBul <br /> APPLICATION IB(HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDOR WBTALL THE WORK DESCRIBED.TIIIB APPLICATION M MADE IN COMPLIANCE NTTII SAN <br /> JOAQUIN COUNTY DfWLOP�M1/EM TALE,CHAPTER 8-11IS.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY//��PU9UC IIIEAI-TR SERVICER,ENVIRONMENTAL HEALTH DIVISION. <br /> AM,JOB ADOMIRMOR AI ( C.-4L-4 4410 PARCEL BIZE/APNI <br /> OWNER NAME ApDI1ESB <br /> fTgNE I <br /> JUO CONTRACTOR r 1 <br /> N <br /> ADDRESS �CE a� <br /> OE I�� <br /> A"CONTRACTOR <br /> ADDRESS UCI AIONE I <br /> TYPE OF WELURIMP NEW WELL ❑ REPLACEMEHT WELL ❑ MOMRORNO WELL E ❑ OTHER <br /> v b ❑ INS INSTALLATION ❑ WTLL YBTEM REPA ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> Ip4❑Rro.N N.P. _ DEPTH SUMP 8-,6t-, FIRST WATER LEVEL_ O <br /> DYPE OF PUMP( <br /> ❑ OUTOFIO <br /> 6ERVE WELL ❑ GEOPHYSICAL WELL S ❑ BOIL BORING e <br /> El DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTAWTION SPECIFICATIONS // A <br /> r❑ <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CAMOW <br /> 0 <br /> ..C.....F��OOMEBTICrTRVATE E)GRAVEL PACKMIZE TYPE OF CABINOBTEEUPVC� DIA.OF WELL CASINOO <br /> w<11 MUNICIPAL ❑DRIVEN DEPTH OF ORI)VT SEAL SPECIFICATION R <br /> ❑ IRXGATgN/AO 11 OTHER GROUT VEAL INSTALLED BY GROUT BRAND NAME E <br /> MONITORING /T / O GROUT SEAL PUMPED: Yr ❑Ha CONCRETE PEDESTAL BY OWS <br /> APRIIOX.DMH G_'T/1_k//al/E_J {� LOCKING CHESTER BOX/STOVE PPE S <br /> ROIOew CONe1RLICTHINANLLINO METHOD: MUO ROTARY / AIR VOTARY AUGER CABLE OTNER <br /> I HE4BY CERTIFY THAT I HAVE PREPARED THIS APRJCATMN AND THAT THE WOW EMIT.SE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.STATE LAWB,AND RULES AND <br /> RfDMT1ON8 OF THE BAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AOENT'8 SIGNATURE CERTIFIES THE F'OLLOWSq:'I CERTIFY THAT IN THE PERFORIAANCE OF THE WOM FOR WHICH <br /> THIS PEOMIi IB ISSUED,I MIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPFNSATON LAWS OF CALIFORNIA.- CONTRACTOR'S RRNO OR SUBLONTRACTIM BIONATURE CERTIFIES <br /> THE FOLLOWNO! -I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS RRAR R ISSUED.I MALL EMPLOY PERSON@ SUBJECT TO WORKMAN'{COMIETNARON LAWS OF <br /> C,MJFOFSBA.• T%THES A//IJ//yC�AJN(//�B/M/Y�ST CALL$,HOU&IINN.wWANCf FOR ALL RFOUMED INSFWTIONe'AT(NISI 4"4M22. C""IJETE OMWIHO AT LOWED DAMA I,,QVIIDED. <br /> BINW X / / /A//� L !//1�+'V F'TA� Till. <br /> ROT RAN 1111 He S..I.I B..I. •m E/ V <br /> I. NAMES OF BTREET8 OR RDADB NEAREST TO OR ROUNDING THE RIORRTY, A, LOCATION OF HOUSE SEWAGE DBPOBAL SYSTEM OR PROPOSED <br /> Z. Oti OF THE PROPERTY,UNSq DIMENSIONS AND NORTH DRCTION. EXPANSION OF BMAnE D@POSAL SYSTEM@. <br /> �. DHMENMWD OUT1UNF8 AND LOCATION OF ALL EXISTING AND PIgFOSED S. LOCATION OF WELLS WRTHIN RADIUS OF ONE NUNODED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS BUNCH AS PATIOS,ONVEINAYS,AND WALXB, ON THE PROPERTY On AOJOINMO PTOPERtY. <br /> 'IAV// SP FILL � �� L�1�` <br /> elfP e 4d <br /> )F <br /> FOA <br /> Wei\ <br /> I <br /> S P <br /> Uu <br /> 'Ice I�- <br /> —� <br /> DEPARTMENT USC ONLY&Lsi /(� <br /> ApplleNbn Aeerolad BY 1 C � C.� 7—C-- <br /> Oravl l,wPmlbn BY �+ N- /'F <br /> UWv/"—�� D.L. �' /•6`PunP L»P.nlron Br 6• -a b D.H. <br /> Owvmuen Iwn.elbn er <br /> ACCOUNTINO ONLY: AID/ FACE <br /> IF GOOFS FEE INFO AMOUNT RFABTTFD CHECK/ SN <br /> RECEIVED NY DATE I1GW111USERVICE REQUEST MUMSDI INVOICE <br /> U I _ <br />