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APPLICATION FOR WELLIPUMP PERMIT <br /> �- SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 368,304 EAST WEBER AVENUE,STOCKMN, CA 95201388 <br /> (203) 469.3420 <br /> ON-REFUN ABLE PERMIT WIRES 1 YEAR FROM DATE ISSU D <br /> (GmpletB In Tr>pr"tal <br /> APPLICATI11K IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOW DESCRIBED.THIS APFLICATKM M MADE IN COMPLIANCE MATH BAN <br /> JOAQUIN CGUNTY DEVELOPMEtNT� 7TITLE,CHAPTER 8L-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRDFfMD fAL HEALTH"ooN. /� �,/ <br /> Joe ADOREG.,APNI 2 '" i I}^"�I •r1,•1.�/ ^ I C/T�FVQ /f LjtJ�fh 1 �I/ ♦ ►AEICtt ERE/APY I 7,G1tl L J <br /> DWNEa'8 NAME�IC Ai'/�f�J`I�EVI -• ADDIEu G./�/ {!/ •�: ����E�~ _PHONE F�� <br /> CONTRACTOR ~i~, 1� I.' /� \7 <br /> ADDRESS 1.`(E -//fJLlz'/ uc� wmNE B <br /> BUB CONTRACTOR <br /> �� ADDRESS {IC>r�` PHONE <br /> OF LY NEW W%LL ❑ REPLACEMENT WELL ❑MONROHINO WELL I ❑OTHER <br /> 1:1'INSTALLATION ❑WELL SYSTEM REPAIR C]CAOASCONNECT REPJUR yAPOR EXORACTION VFELL <br /> UN—❑1`epW N.P,� Of FTN pumps"i-0—FT. <br /> (TYPE OF PUMPI FBIBE WATER IlVEL O <br /> ❑OUT-OF-6ERVICE WELL ❑GEOPHY61CAL WELLS BOB. ISPm SDA <br /> ❑OEBTMICTICN: <br /> IN ENDO)WLt TYPE OF WJU CQN4TRUCTIIFICATIONt ♦I <br /> 1 ❑INDUSTRIAL ❑OPEN BOTTOM jj DIA.OF WELL EXCAVATION LXA.OF CONDUCTOR CASINO ^14&Aft- p <br /> ❑ DOMESTICNAIVATE RAVEL PACK1812E Z-` TYPE OF CASMGMTEEUP/C_S!C c ( DIA,OF WELL CASINO L p <br /> 6 1II C❑0 <br /> .3(. U MUN <br /> 'PGATICWAL ❑❑DRIVEN DEPTH OF GROUECIICATON <br /> 'oN/AO OTHER OUT REAL INSTALLED BY (-i Q ORDVT BRAND NAME <br /> MONITORING GROUT SEAL PUMPED'0Tw--U <br /> �N <br /> Ne CONCRETE PEDESTAL BY DRRLER O Y- ❑Ns S <br /> 1 APFROX,M"" Lomom CHESTER BOXr6TOVE PIPE �u y�` S W <br /> FROPOSED CONS!"RUCTIONMAILUNG METHOD: MUD ROTARY^ AIR NOTARY AUOER^, CABLE OTHER Fe�'�/'NI- fM i•/.1 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND•HAT THE WOW WILL BE GONE IN ACCORDANf.E WITH SAN JOAQUIN COUNTY ORDINANCES.STATE UVJs,AND RULES AN <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCPNBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT INTHE PCR OFBAANCE OF THE VdUFK FOR WHICH <br /> THIS PERMIT 16168UED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOAKMAN'S COMPENSATION LAWS OF CA'JFORNIA.' CONTRACTOR'S INNING OR SUBCONTRACTINO SIGNATURE CERTIFIES <br /> THE PDLLOWING: •1 CERTIFY THAT IN THE PFRfORALANCE OF THE WOR'L FOR WHICH Two pERMrT IS 186VEC,I SHALL EMPLOY KA60NO SUBJECT 70 WORGOMM•S COMKNSATION LAWS OF2 <br /> CAUFOP"A.• THE APPLICANT CALL 24 IIOU1W IN ADVANCE FOR A31 REQUIRED INSPEc NS AT 12P*1 460-31422, COMPLETE DRAWING AT LOWER AREA PUOVIDFO. <br /> 1 <br /> 61Fn.!X— I LlJ..�Jr,� jvC2 cD.,. � <br /> PLOT PLAN ID—t.8uw 6u1. t. <br /> 1. NAMES OF STREETS OR ROADS Nf ARE6T TO OR BOUNDING THE PROp""TY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYSGEM OR p"opoGED <br /> 2. OUTUNE OF THE MOPEROY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2, DIMENBIONED OUTLINES ANO 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,DINVEWAYS,ANO WALLS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> MEN <br /> :.. ... :.. ... 1f" S <br /> APR , 1997 <br /> ..,........... <br /> ........ . . <br /> .t:P:T,1sL `IFA IJ� <br /> :. . : . ._. . .. ...:...:. : ...:. .' .. • . . . .. . . Y��, : etc i�.�y:.....A:. . ;. <br /> :...... <br /> r <br /> D®MOMENT USE ONLY <br /> Applle.tbn ACe.p I.J By_ D.l. '7_Ar.._ <br /> G,mn ln.pecuen By S 4 P.F.. <br /> P InF P V.n By _. _D.I. fr/l/f7 <br /> U,rk,ctbn I.�P.alen Ay pne <br /> comma�r.:__pl V �) 3 00 <br /> ,4.0 ki3 o.S`VL✓S <br /> ACCOW471NG ONLY: MDI FACT rL oif)12 02; <br /> PE CODE* FIX INFO AMOUNT RUATTED CNEC MM 11ECOVED BY GATE ►B'iMli/ /INVOICE <br /> 6 l r! <br /> 05 o z I o <br />