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.APPLICATION FOR WELL/PUMP PERM'—) <br /> SA.. ,:OAQUIN COUNTY PUBLIC HEALTH SE..DICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> . (209)468-3420 �O Fly <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompNb in Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUtN COUNTY FOR A PERMFT TO CONSTRUCT ANDIOR INSTALL THE WORD(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WTTH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAFFER 9-1115,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APNI t 'Z (�J _S l h_2�2 _�. CITY 4 A <br /> - —r-QIZ PARCEL S12ElAPNI <br /> OWNER'S NAME - ADDRESS PHONE# <br /> CONTRACTORTOR pAE86 S LIC# PHONE#43 i /7V&7 <br /> (qua CONTRACADDRLICESS i a`�� r a q f 232 PH.NE 1 <br /> TYPE OF WELLMUMP• ,❑mac NEW WELL 13 REPLACEMENT WELL ❑ MONITORFNO WELLI 11 OTHER ' <br /> OM S H L` K►F INSTALLATION El WELL SYSTEM REPAIR 11 CROSS-CONNECT REPAIR 11 VAPOR EXTRACTION WELL I J <br /> RYPE or PUMP) Naw 11Rapalr H.P. r '-bEPTH PUMP SET FT, FIRST WATER LEVEL p <br /> 11OUT OF•SERVICE WELL ❑-GEOPHYSICAL WELL# Cl 9011 BORING g <br /> ❑DESTRUCTION! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> 13 INDUSTRIAL •• ❑OPEN BOTTOM IA <br /> D .OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p <br /> 13DOMESTIC/PRIVATEDOMESTICIPVATE L1 GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC DIA.OF WELL CASING [� <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> © IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITOMP40 GROUT SEAL PUMPED: [IV. ❑Ne CONCktE PEDESTAL BY DRILLER:❑Yes <br /> 11 No S <br /> APPROX.DEPTH LOCKING CHESTER SOXISTOVE PIPE <br /> S <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY!THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING;•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHFCH <br /> THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HnVNG OR BUB-CONTRACTING SIGNATURE CERTI ES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA" TH APPLIC MUST CALL E4 HD S IN ADVANCE FOR ALL REQUIRED INi►ECTIONa AT t2991444-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED, <br /> Slaned X - Two <br /> PLOT PLAN IDIaw to SeWe?Seale 'to <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PMPOSEO <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3, DIMENSIONEb.OUTUNEB AND LOCATION OF ALL EXISTING AND PROPOSED - S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. _ <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK& ON THE PROPERTY OR ADJOINING PROPERTY. <br /> a <br /> Y <br /> If ... . <br /> r rL UG <br /> �W <br /> IN� v;ot­ <br /> NV1,gQr � <br /> JA?ETJFq��FA17� <br /> _ DEPARTMENT USE ONLY <br /> APPiloetlen Aaaaptecl By. pNe �i Area <br /> Moto tnapeatbn By e Pu p Inrpeatton By G co Dats� <br /> Deatn.O.n Lnpwtbn By. Date <br /> Col.�me.ga: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC ABH RECEIVED BY PATE P"IMITI#ERVICE REQUEST NUMBER INVOICE <br /> Pub.Health Serv.-Enviro.173(1197) <br />