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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> "— 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)469-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 TEAR FROM DATE ISSUED <br /> ICOMpkDI In TLIpDeflfl <br /> F APPLICATION 191/ERE BY MADE 70 THE SAN JOAOIJIN COUNTY FOR A PERMIT TO CONSTRUCT ANTIMM INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1116.3 AND T/HE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC 14EALT14 SERVICES,ENVIRONMENEAL HEALTH DIVISION./^^ <br /> JOB ADORE89/OR AM' � JC p V, CITY RI n=H�y1 PARCEL BNFIAPN/ <br /> OWNER'8 NAME {/I, �_�! f ✓! /T /�!)TLl�.,-'C� PHONE EJ- �9 <br /> CONTRACTOR L/1�[C? i YS -I 1'I✓C i' ADDRESS y F7/.�"r S LK "Zt PHONE 1/ z-//2J <br /> SVB COMPACTOR --YY ADDRESS � 1 <br /> -�L`/Oct PHONE•, . / <br /> TYPE OF WELLElJPUMP: NFW WELL ❑REPLACEMENT WELL ElMONITORING WELL/ Din GOT.. T I[,,(- <br /> ..., ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CR09R CONNECT REPAIR ❑VAPOR EXTRACTION WELL/ J <br /> 11N-❑ ev RNr N.P. DEPTH RUMP BET_FT. FIRST WATER LEVEL O <br /> (TYPE OF PVMPI <br /> ❑OVTOF BFRVICE WELL ❑GEOPHYSICAL WELL/ ❑ FOIL BORING B <br /> ❑DESTRUCTION' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` A <br /> ��ET <br /> ❑�INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION IA.OF CONDUCTOR CASING <br /> jD <br /> 4l-DOMESTICT VATE RAVEL PACK/RIZE TYPE OF CA81N0/ST EFVP'VC VG plA.OF WELL CASINO p <br /> ❑R/BLICRAUNICRPAL ❑DRIVE" DEPTH OF ORDM SEAL I.Ce6SIECIFKATION R <br /> ❑IRRIGATION/AG ElOTHER GROUT SFAL INSTALLED ,/F P <br /> BY ALS-WIC GROUT BRAND NAME ItI V L I �l'ti. E <br /> ❑MONITORING GROUT 6FAL PUMPED:JM-y- ElCONCRETE PEDESTAL BY DRILLER:ClYM e S <br /> \/ <br /> APPRO K.OFDTN ! J <br /> �[ 5 ) LOCKING CHESTER BOXGHOVE PPE S <br /> PROPOSED COMSTAUCNON/ORILLINO MrIHOD: MUD ROTAM AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APLICATgN AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAOVRN COUNTY.HOME OWNER OR LUCENEIED AGENT'S SIONATL/RE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF THE WOW FOR WUM" <br /> THIS PERMIT 18 ISSUED.1 SHALL HOT EMPLOY PERSONS MMJFCT TO WORKMAN'S COMPERGAHON LAWS OF CAUFFOWA.'CONTRACTOR'S HIRING OR BUBLOHTRACTING SIGNATURE CERTIFIES <br /> T11E FOLLOWING: '1 CERTIFY THAT M TILE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORIOMAN'S COMPENSADON LAWS OF <br /> CALIFORNIA..' THE APPIJCAA.l MUST CALL SI URf IN ADVANCE FOR ALL RFOLMED INSPECTIONS AT IIOSI 4tl_/427.COMPLETE DRAWING AT LOWER AREA PROVIDED. /{''Y <br /> BlPned X �f l L ✓1(11K al H,I.' �1 1.! 11" D.t. 3-7-12r- <br /> PLOT <br /> '7_12`^ <br /> PLOT PUN M—to Be-I B-I. <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. f. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> \ <br /> 1.OLGUNE OF THE PROPERTY,GR GUG DIMFNSIONS AND NORTH DIRECTION. EXPANBRON OF SEWAGE DISPOSAL SYSTEMS. <br /> J.DIMFNBIONED OUTUNFB AND LOCATION OF ALL EXISTING AND PMPOSFO S. LOCATION OF WELLS WITHIN NAZIKUS OF ONE HDNORLCO FIFTY F'T (� <br /> STRUCTURES,SIOLVOINO COVERED AREAS SUCH An PATIOS.DPVEWAY�B\ANO WALKS. ON THE PROPERTY OR ADJOINING mopcn TY. �\ <br /> .. : ..... <br /> Lij <br /> f <br /> O , <br /> 10A <br /> til( <br /> MARE� <br /> 3AN JOAQUIN COIJ T`. <br /> . .YUEHJC HEJaLTH T <br /> -;NVIHnt`iMEt•IT„Ii HFA7 .. <br /> 011-TM-T USE ONLY <br /> A Ile.Rlen Aeee�Id BY v` ON. 1 / V V A- <br /> / C <br /> [(p. <br /> (>r ut Rri L bn BY O.Ls l NwnP Inrv..cllvn BY D.t• <br /> o,a,t.tlen In. Ian a mte <br /> 2�, �u �il� Lit Wi w o G C,c <br /> ACCO VNTIN0 ONLY: AIDI FAC/ <br /> S JU v1^r?l F <br /> PE CODES FEE INFO AMOUNT REMITTED /IECI MASH ' RFCDVED BY DATE PBO1nT/fFLLVICE REOVEST NVM99t INVOICE <br />