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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,904 EAST WEBER AVENUE,STOCKTON,CA 95201 <br /> 1209)4SB-3420 <br /> [1011 RUTUNOABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICem'NIB In TRIAIk&1&I <br /> APPLICATION IS HERE BY MADE TO THE CAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL TNT WORK DESCRIBED.THIS APPLICATION It MADE IN COLIMLANCE WITH BAN <br /> JOAOUSU COUNTY DEVELOPMENT TITLE,CHA ER 9-1115.3 AND THE STAND`ARD&'OFF)SAB <br /> `N JOAOUIN COUNTY PUILIBID <br /> ICC HEALTH SERVICES,ENVNMENTAL/KALT14 OIVIMON. <br /> Jos AOORESSIOR AP". UO�A `. �OV\`\\A`VOz 1`V CET�(I 'i;l'VJ � PAR_CEEL SREIAPNg t/I <br /> OWRERS NAME`^��M C\'i�`m AOOMOR U`O "i=—.S GX\`\`r\\VN 'V PRONE! 3)•\y(5e4o <br /> CONTRACTOII Y\V��Y`\�«h\ ��h�p� Jy \�1�NQOL ADOPE66 l\?�� n1aR1W UC/��/S��\ MDNE F�LJ1•yD <br /> SUS CONTACTOR ,v`T•� ADORE66 UCI RgNE <br /> TYPE or WELSFUMF- ❑NEW WELL ❑REPLACEMENT WELL Cl MONITOR WELL E ❑OTHER <br /> I <br /> INSTALLATION ❑WELL SYSTEM REPAIR ❑CHOSBCONNECT REPAIR ❑VAPOR EXTRACTION WELL <br /> / J <br /> SV�n �Nwv❑II.PJr N►\_ OEETNIVMPSET�O FT. FIRST WATER LEVEL &'61' O <br /> OYPE OF PUMP <br /> _ --' - J _ _ ❑OUT-OP-SEINKE WEIR ❑OEOPUYCICAL WELL l _.e y SOIL SOPNO <br /> `} INTENDEP WE TYPE OF WELL CONSTRUCTION SPICUICAtIONd A <br /> I ❑SIOUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCtORCAMN1O O <br /> {f DOMEOTICJRSVATE ❑GRAVEL►ACKRRE TYPE OF CABINO.IEElRVC L4LI M DIA.OF WELL CA61N0 t.y l I O <br /> ❑PUSUCA,/UNICIPAL ❑DRIVEN DIM"OF GROUT CEAL SFTCOX:ATION A <br /> ❑IIURUAION/AO ❑0111" OROITT SEAL IN/TA E <br /> D MONITORING 1t�`` UNOUT SEAL PLM ❑Y- U V. p L S D I IFR❑Yw ❑N. S <br /> A►PRDX.OEPTN 1�V' LOCKING CHEATER B".MTOVE PPE BBB���4 IT 999 333[[[ S O <br /> ROPOSSD COMTRUCTIONRNELUNO METHOD:MUD ROTARY AIR ROTARY refm>, a flay,Cp� <br /> 1111-116Y Cl IT"THAT I IIAVE,PREPAW.D THIS"",ICATgN ANO TIIAT TINE WORK VALL BE DON ^r f,BATF LAWS AND RUIFf.AND <br /> REOULATIONS OF TIE SAN JOAOUIN COUNTY.HOME OW NER OR 110ENSED AGENT'S SIGNATURE FF17VAJ M.IC GE 1[.1',jIt�A1T•'I�N�i H@D�»OMAMC710N0 HEW UREFOR WHICH <br /> CERTIFIES <br /> RMS PERI.Mi K ISSUED,I SNML NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP%K4A '� rLjC�lllinNyryRE' FL'M Y <br /> THE FOLLOW '1 CERTIFY THAT NI TIE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIWAM'S COMPENSATION LAWS OF o <br /> CALIFDRITIA.' THE AePPLICCA`N`T MUSTCALL74 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT IMI 4684427. <br /> COOMPLETE DRAWING AT LOWE"AREA PIONPED.llx— E\�\4 V <br /> St—d <br /> 1 ROT PLAN m•.wh Sn.W Sa.I. C]1_ <br /> i.NAMES OP STREETS OR TOADS NEAREST TO OR BO UNONMO THE POIT!", 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 7.OUTLINE OF TIE PROPERTY,GIVING DIMENSIONS ANb ORTH b .TKNI. EXPANSION OF SEWAGE INDMOAL SYSTEMS. } <br /> a.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PHOPOSEU C.LOCAl1ON OF WELLS WITMN RAD"OF ONE FIUNDIEO FIFTY R. <br /> STRUCTURES,INCLVDRAT COVERED AREAS SUCH AS►ATO&,DRIVEWAYS,AND <br /> WAUK9. U ON THE PMPERTY OR ADJOINING PEIDPERTY. <br /> AYMEP <br /> .. ... ... .i. !. .... . <br /> 1 RFCE VES. <br /> SAN JO OUfN(,OUL'ti <br /> PUEIUC HEALTH SEAvlccsi <br /> DIVI <br /> ElJvrf{ONHIENTAL HE4TH DIVISION— <br /> 10 <br /> :... <br /> :.. <br /> _. . <br /> v <br /> APPIk.S.n A...PIRI By 4�!1(//�]6 AIM - L v <br /> Gr.,A In,Ps.11q,■Y D.I. P—v Sy_ <br /> INR—I— MY b.l. <br /> r <br /> ACCOUNTING ONLY: AOI FAC! <br /> PE LOOFA FEE INFO AMOUNT HINBITED C/1ECXI tAl. RECTIVEO SY DATE F9DAITUSDIVICE REOUEAT NUMBER INYOMN <br /> 3`d� DSb -oo <br /> Pub.He&tth Serv.-Errviro.173(3/96) <br />