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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> 304 EAST WEBER AVENUE,HEALTH <br /> ON, CA 52S <br /> EVIRONMENTAL 2 c®py <br /> (209) 468-3420 <br /> NOR-REfUNDABEE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICBmpMu M TFIpRCRn1 <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INET ALL THE WORE Of SC FIRED.THIS APPSICATION IB MADE IN COMMIANCE WRII SAN <br /> JOAOUIN COUNTY DEVELOPME/NT TITLLE,CHAPTER/9--11116.3 AND THE STANDARDS OF BAN JOAOUIN COUNTYY MBLICC�IIEALT14 SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODRESSPORAMI <br /> r1 <br /> PAMFl.RIZEJAMI <br /> NE� pp <br /> OWNEN9 NAME X a <br /> CONTRACTORUCI INONEIV [ <br /> (— <br /> /di'tiJ <br /> PUS COMMCTOR ADEMBIL UCI PHONE I <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ RETRACEMENT WELL ❑ MOFSTONM WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT S REPAIR ❑ VAPOR EXTRACTION/WELL I❑NIrr F�RRENr H.P. OEM"MMP e0 tag,R. FIRST WATER LEVEL O O <br /> DYPE OF MMPI <br /> //� ❑ OVT-0F SERVICE WELL mow ❑ OEORbSIICCALL WELL I /❑T/COIL BORING <br /> / S <br /> ❑OESIJ11bfNN. .ESA�.L(//�+�� L�O/ C CaJ�'C/V K�_F.�t /Lam,��L,Q.[ VJV 1--y1/>� <br /> INTENDED UI! TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ,❑J INIXISTMAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASIM O <br /> UI DOMEBTICRIYVATE ❑GRAVEL PACKMIZE TYRE OF CABINOIBTEELIPVC CIA.OF WELL CASINO O Jf O <br /> L[-J, tVBUCAIVNICMAI ❑MWN OEM"Of GROUT SEAL BIECIFICATION R <br /> ❑ IRRIOATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME f <br /> ❑ MOMTOMM GROUT SEAL MMF*O: ❑Vee ❑No CONCRETE PEDESTK BY DRILLER:❑Yw ❑Ne 5 <br /> AMTOX.OVTH //� / LOCKING CHESTER SOX/STOW RR 5 <br /> PROPOSED CONSTRUCTION AILUNO METMD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HF4BY CERVFY THAT I HAVE PREPARED THIS APPLICATION AM THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN POAOUIN COUNTY ORDINANCES,STATE LAWS.AND MULES AN <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY, HOME OW'INR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERRFY THAT M THE REREORI.IANCF OF THE WORK FOR WHICH <br /> THIS KFART IB ISSUED.I MIAIL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENIATION LAWe OF CAIWOPMA.• COMMCTOW S AIRING OR SUSLONTRACTIM SDNATURE CERTIFIEI <br /> TIN fOLLOA. : 1 CERTIFY THAT M THE NO tl41 IMA V T11F TW 1K FOR W111CH TMI iEN.1R 1I ISNED.1 SHALL f. RRl10NS SUBJECT TO ER AM AN'I COMPENIATBN UWt OF <br /> CALIFGRMA.• IRA CANT MUST CA"-j!4 HOARY 1 ADV AMC!FOR ALL REOURFD INIP[C� •AT IS011 Itli1Sl. COMItETE(NIAVJINf1 AT EDIFIER AREA AIGNDE <br /> M.'.. .cG ^YF'L� TMe <br /> ROT"N ID,—le Seelel Poole •Ie <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PTIOPRTTY, 1. LOCATION OF HOUSE BEWARE DISPOSAL IYSTEM OR ITIOIOBED <br /> Z. OUTLINE OF THE PROPERTY.ODRINI DIMMIIONI AND NORTH DIRECTION. EXPANSION OF SFWAOE DISPOSAL SYSTEMS. <br /> T. DIMENSIONED OVTUNFI AND LOCATION OF ALL EXISTSb AND PRICI OSfO 1. LOCATION OF WELLI WRAITH NIDIUI OF ONE HVNDIIED FIFTY IT. <br /> STRUCTURES.INCLUDING COVERED AREAS SACH AS PATIOS,DRIVEYJAYS.AND WALKS. ON THE POPERTY OR AEAHNBFCD iEIORNTY. <br /> Al <br /> -- <br /> r,Cc <br /> OCT 2 700 <br /> FAN JOAQUIN COIN:Y <br /> PUBLIC.HCALTH CEgVICES C <br /> ENVIHONMI;M,LY EhLIH U,bIS1UN - SPIE O� I <br /> c <br /> T^ ODVM M T VI[ONLY ad+- I -z- <br /> 01.0 <br /> Oreu I—000lb Br D.0 Awne ImPeeSen By OFu <br /> Owbwlbn I—Fool n ST D.q <br /> CenmvXe <br /> ACCOUNTING ONLY: AID# FACT <br /> It CODES FEE IMO AMOUNT REMITTED HFCR ICAIN RECEIVED BY DATE PEIWB T/I VICE REQUEST NUM8EI1 INVOICE <br /> 050 ' z <br />