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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICemplSt{ in TTIpDEAtI) <br /> APPLICATION M MERE BY MADE TO THE BAN JOAOVIN COUNTY FOR A PERMIT TO CONSTRUCT ANDOR INSTALL THE WOR(DESCRIBED.71118 APPLICATION I8 MADE IN COMPLIANCE VAT If SAN <br /> JOADUIN COUNEY DEVELOPMENT Tr L ,,[CHT ER 8-1118.3 MDT11II STANDARA/p�L91F BAN"AMIN COUNTY PUBLIC HEALTH SERVICES,EI NRONMENTAL HEALTH DIVISION.JO/AOOREBSOR LPN/ 3D _:scujlr'a I�11' CITY M PARCEL BIIVAPN/.SAer C-] <br /> OWNER'S NAME f"LcV r ADDRESS 1 BONE I <br /> CONTRACTOR4malell ArIIIIM4 -ADDRESS LIC. W3k3 77q <br /> SUS CONTRACTOR AMMBS EIC/ PHONE <br /> TYPEOF WEIl/PU1 . X NEW WEU ❑ PEPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> So}/I� A❑ NWTION ❑ WELL SYSTEM REPAIR ❑ CIRUB&CONNECT REPAIR ❑ VAPOR EXTMCTION WELL I J <br /> 0- XNwv❑MW H.P. '2,, L OEM"PIMP BET2FT. FIRST WATER LEVEL_ O <br /> RYPE OF PUMP <br /> ❑ OUTS SEIWICE WELL ❑ GEOPHYSICAL WELL/ ❑ BOIL BORNO B �, <br /> ❑DESTRUCTION: <br /> a <br /> INT TYPE OF WFIL CONSTRUCTION{PECIFlCA /1 q <br /> ❑ IHDIISTRIK ❑OPENBOTTOMDIA.OF WELL EXCAVATION �eLa DIA.OF CONDUCTOR CAMM D <br /> DOMESTICARIVATE ❑GRAVEL PACXIBIZE /M TYPE of CASNOISTEELA`VC A010IA.OF WELL CAMM A O <br /> ❑ PVBLICIAIIINICIPK ❑ORVEN ---YYT���--- DEPTH OF GROUT SEAL . - SPECIFICATION R <br /> ❑ mROAT1ONIAG ❑OTHER GROUT SEAL INSTALLED BY D e GROUT BRAND NAME (Tt�A Rh C�f E C <br /> ❑ MONITORING <br /> APPRO%THEN ; / � 7 S / OROUT BEA LOCKING C VY <br /> YfR BOWSTOW PPF CONCRETE ROESTK BV pBLLER J{I YM ❑Ns { �, <br /> PROPOSED CONSTRUCTIONI AIMINO REVIEWS: MUD ROTARY AIR ROTARY AMER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOMANCF WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE BAN"AWN COUNTY. HOME OWNER OR LICENSED AOENT'8 SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PEREORMANCE Of THE WORK POR WHICH 1` <br /> TMS PERMIT IB ISSUED,1814AU NOT EMPLOY PERSONS O UBJECT TO WORRMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S NIRNG OR SUS{ONTMCTINO SIGNATURE CERTIFIES G' <br /> THE FOLLOWING: -1 CERTIFY THAT N THE PERFORMANCE OF THE MORN FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERBON8 NUWECI TO WORRMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE CA VST CA E4 HOURS IN ADVANCE FOR ALL REGUMEO INS TIONS AT ITGm 4011 A11. COMPETE DRAWING AT LOWER ATEA PROVIDE . <br /> SIP,W% On/-Ji7/yx <br /> POT PAN Otnv Is Bartel Beele 'le <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2, OUTLINE OF THE PROPERTY.ORRW DIMENSIONS AND NORTH DIRECTION. EXPANSION OF OMAOE DISPOSAL SYSTEMS, <br /> T. DIMENSIONED OUTLINES AND LOCATION OF ALL FXIEEING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. <br /> STRUCTURES,INCLVDING COVERED AREAS SUCH AS PATIOS,OPP SWAYS.AND WALX8. ON THE PROPERTY OR ADJOINING PROPEREF. <br /> �'AYMENT <br /> 1998 <br /> I <br /> SAN JOAQUIN CO <br /> INI1171�'S"�I"^9 — <br />