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1 <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> .� SAN JOAQUIN COUNTY PUBLIC HEALTH SERV(CES � � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> RO. BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA 95201388 V <br /> 1209) 4663420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> '(Complete In Triplicate) <br /> APPLICATION IS HERE SY MADE TO THE BAN"A"COUNTY FOR A PERMIT TO CONsTnUCT ANDI IR INSTALL THE WORK DEBCRIBEO.TIIIS APPLICATION IB MADE IN COMPLIANCE W TTN SAN <br /> JOAW W COUNTY DEVELOPMENT TITLE.C117 8-1116.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUIBUIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DTVI ^" —1 <br /> JOB AODREBBA3R APNP 1 7 / rY TI S"['AQA� , �� _ PARCEL BRFMsr. e T <br /> /� ��'///IIF �l S <br /> ONMEp'e NAME A • Y 13 ^eJ".L'-'^-\•C c..c. a- PHONE°, a 7 <br /> ��J pp 1/L ?EIF <br /> CONTRACTOR �TY�6 )Q \V` CDC.\I.EFVS ADDRESS Z ;"� ��,E �� lIC1 NEP <br /> "CONTRACTOR S S. L.nF5 C4] �,L,�[T��.i1C_ Ao as IIs d9 T&q ad /� LICP a76l Ao PEHINE J E Q <br /> TYPE OF WELLBPMP, WELL ❑ REPEACETMENT WELL El MONITORING WELL P 1-1OTHER <br /> YALlAT10N ❑ WELL SYSTEM REPAIR LlCR0s9 CONNECT REPAIR ❑ VAPOR EKTMCTMN WELL E <br /> F <br /> LY New❑Weoelr H.P. OFMI PUMP SI IT. FIRST WATER LEVEL 1 <br /> tTYPE OF RUMP) <br /> ❑ OUT-OF SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ BOR BONNa A <br /> ❑DESTRUCTION: <br /> INTENDED USE_ TYPE OF WELL CONSTRUC11ON SPECIFICATIONS A <br /> �.,J/ ❑OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> INIYOMESTIC,TNVATE ❑GRAVEL PACKIRIZE TYPE OF CASINOISTEELTVC IRA.OF WELL CASING D <br /> ❑ PUSLICRAUHICIPAL .❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION..,,// n <br /> ❑ 1RRIGATIONIAG W OTHER coat Mtlal A.I GROUT BEAL INSTALLED BY GROUT BRAND NAME _ <br /> ❑ MONITORING �/�� / e AA OROIIL SEAL PUMPED: ❑Yr (IN. CONCRETE PEDESTAL BV DRILER:❑Ve. ❑Ne <br /> APMOX.DEPTH _ J /xfr� �Nr��l•e7�> LOCKING CHESTER BOXALLOVE RPE ,y <br /> PROPOSED CONBTIUCTpN/dtlWNO METHOD: MUD ROTARY AIR ROTARY AUGEfl CABLE OTHER <br /> I HF9 BY CEITTKV THAT 1 NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.ANO WILES ALIO <br /> NOULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TIE WOR(FOR WHICH <br /> THIS PERMIT IB ISSUED,1 SHALL NOT EMROY PERBONB SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA.- CONTMCTOIYS HIRING OR BU"ONTRACTING SIGNATURE CEWTIFIF9 <br /> UIE FOLLOWINO -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMROY PERSONS SUBJECT TO WORKMAN'9 COMPENSATION LAWS OF <br /> CALIFORNIA.' TME AP CA T MUCALL HOW 1N ADVANCE FOR ALL REQUIRED INSFECTIORG AT IxEal BaaJA=a. COMPLETE DRAWING AT LOWER AREA PROOVIDED. <br /> Slarve x Thle <br /> ROT PIAN Ia...a W.)T .le 'le <br /> 1. NAMES97METB OR ROADS NEAREST TO OR BOUNDING THE PIIOTERTY. M, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPIRED <br /> i. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE OIRMSAL SYSTEMS. <br /> 3. DIMENSroNEO OITLUNES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOWED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEW YS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> q -� J <br /> w J <br /> A q <br /> b �9 � <br /> ENT USE ONLY7 — _l+i�./� <br /> npone.nnn AC.—F1 BY V — D.Ie O L A,. Z_i �/LJlT <br /> GroU MDOee,len OY MI. Pump hw.0 D a /'! ONe L/ <br /> Oslnellen Ir,.Pecrbn 8, Oct. <br /> ACCOUNTING ONLY: No# FACT <br /> R CODER FEE INTO AMOUNT REMITTED TIECK ASMI RECEIVED BY DATE PEN.RTISM"CE REQUEST NUMam INVOICE <br /> 3 I D R. 7j <br /> Pub.Health Serv.-Enviro. 173(3/96) <br /> ,'PooLla3�1 <br />