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APPLICATION FOR WELLIPUMP PERMI- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PCO. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201588 <br /> (209) 488-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBmpMte In TrlplknEl <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SI <br /> JOAQUIN COUNTY DEVELOMENT TITLE,CHAPTER 8-1115.3 AND THESTANDARDSOF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODPESBA)R APNI \,\ 'VCITY CITY ':'.A Q C-,` I�Q1'^\\ PARCEL SIZE/APN! Q <br /> OWNERSNAME <br /> C f`\ ADDRESS . �](����. �0�4 be-1 ^�1 I PHONE! <br /> CONTRACTOR `\h��V Z���.\ VM\ ADDRESS`\Lk, \V .��V ��Uj UCI;,u A4\ PHONE# � �]uI?` `Q] <br /> SUB CONTRACTOR ADDRESS UCS PHONE# <br /> TYPE OF WELLIP1MP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> �n_ Nsv❑geP.lr M.P.�� DEPTH PUMP SFTL-JLFT. FIRST WATER LEVEL <br /> TYPE—OFMMPI <br /> ❑ OUT,0F.SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING t <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING Z <br /> 11\\ U <br /> I�DOMESTICIRSVATE }��-pMGRAVEL PACK/SIZE 1 V TYPE OF CASINAISTEELN C DIA.OF WELL CASINO I <br /> IJ PUBUC/MUNICIPAL NDRIVEN DEPTH OF GROUT SEAL SPECIFICATION A <br /> ❑ IRRIGATKIN/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> E <br /> ❑ MONITORING J\ GROUT SEAL RJMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLER❑Y. ON. (Z <br /> APFROX.DEPTH Q L ) I LOCKING CHESTER BOX/STOVE RPE ,{ <br /> PROPOSED COMSTIIUCTIONIDISWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK.WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AN <br /> REGULATIONS OF THE SAN JOAWIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WPIC <br /> THIS PERMIT IS ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS{ONTMCTING SIGNATURE CERTIFIE <br /> THE FOLLOWNG: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS BUWECT TO WORKMAN'S COMPEABATION LAWS O <br /> CAUFORNIA.' THE APPLICANT MUST CALL 24/101110 IN <br /> ADVANCE FOR ALL R[OU111�PECTIgO�ME�AT`1I7(NH'L409Y 22. COMPLETE DRAWING AT LOWER AREA PROVIDED. [��\ <br /> Bl'r X � TIII. <br /> ROT MN ID,e.,1e SPNeI SUIa'He <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> Z. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMB. <br /> 3. DIMENSIONED OUTLINPS AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ao 0oo i <br /> /0 - p <br /> W <br /> 1?4l ,�I . d li <br /> MAR 19 199tb <br /> I'U60C HEALTH SERVJ(,;E <br /> _NVIRONMENTAL HEALTH DIV($IC)C_. �N Q <br /> I <br /> OFPARTMENT USE ONLY <br /> P �T <br /> AOPllaetlon Aee,gted Br �L�I'CT-y—l! A. Lr <br /> C re�A Impstlen BY D.te Pump Irvvee<len BY )A /` De. <br /> Osbwlbn IINPeetlen By O.m <br /> Cemmenb' <br /> ACCOUNTINO ONLY: AID# FAC# <br /> PE CODES F AMOUNT REMITTED NEC #/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />