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APPLICATION FOR INELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERV• <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O, BOX 988, 304 EAST VVEEIER AVENUE, STOCKTON, CA 95201388 <br /> 12091499-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS IIERE BY MAGE TO THE BAN JOAOVIJ ,1 <br /> PERMIT TO CONSTRUCTNDp <br /> AR <br /> atel <br /> COUNTY FOR A PINSTALL THE WORK DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WTD•SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESB/OR APNI_70X T(pifl +vK <br /> CT! ,S l'[�n PARCEL BIZE/ARYJI Op7`7/0 _0Q <br /> OWNER'S NAME <br /> i <br /> coNTADORE9e_ PaAtV14 nt, {J'ot/c.1a.T gbNErdo9-�(7?-RSCOMPACTOR ��=—•I,�.a;� .. �'�VIJnC 7'Inr <br /> _- �_1�v..r_`W•. . ApOREBB {.D_BoX nI S /A LICI HONE I� JL <br /> PUB CONTRACTOR l�oQ <br /> PHONE,- <br /> TYPE OF WEU/PUMP �1 NEW WELL ❑ REPLACEMENT WFLL Iq MONITORING WELL r Aa KI-5 ❑ OTHER <br /> •J�------ <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR <br /> ElNew❑R..11 N.P. ❑ VAPOR EXTRACTION WELL I J <br /> RVPE OF PUMP• DEPTH PIMP SET PT. FIRST WATER LEVEL <br /> ❑ OM-DF SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ MR.BORING G <br /> ❑DESTRUCTION: B <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ /I It <br /> A <br /> ❑ OOMESTICITIVATE ®GRAVEL PACX/BRE lj Lj- kf TYPE OF CASINO/STEEL/PVC ht DIA.OF CONDUCTOR CASINO p <br /> ❑ PJBUC/MUNICIPAL ❑DRIVEN dA.OF WELL CASINO_ 'd IT O <br /> DEPTH OF SEAL <br /> LUE }}��P ������(( SPECIFICATION 4n R <br /> ❑ IRRIGATION/AD ❑OTHER GROUT SEAL INSTALLED BV�IJ P 11 LEJy '11 <br /> LJ MONITORING GROW BRAND NAME E <br /> APPROX.DEPTH GROUT SEAL PUMPED: ❑ N. CONCRETE PEDESTAL BY GRILLER;p Y— CIN. S <br /> LOCKING CHESTER <br /> TEfl SOk/STOVE PPE <br /> PPIOPOBED COMBTRIJCTONIGRIWNG METIHOO: MUD ROTARYCABLE 5 <br /> AIq Po)TARY 1� AUGER <br /> OTHER <br /> I HEBF 11 CERTIFY THAT 11NAVE PREPARED THI9 APLJCATON ANO THAT TNF.WOFK WRL SE DONE IN ACCORDANCE WITH SAN JOAGVIN COUNTY ORI:JINANOES.STATE LAW..AND RULES AHD <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY. NOME OWNFR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOOL MR WHICH <br /> TIIIS PERMIT IS ISSUED,1814ALL NOT EMPLOY PERSON.SUBJECT TO WORKMAN'S COMPENw AIRON LAW.OF CALIFORNIA.- CONTRACTO W S HWNO OR OUR-CONTRACTING 61GNRIIPE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PEgwONB gVBJECT TOW-CONTR C COMIgNATURE EMI OF <br /> CALIFORNIA.-L/T,H�JE/A�p�gIC/JAMTOMUJT CALL 24 NpUW IN ApVAMCE FOq ALL gEOLR"M IN$R TT NNS.AT•]Owl AtlJFS}, COMPLETE DMtNNO AT LOWER AREA PROVIDED. <br /> .IPI,e.X /M V IY�NN Tlllw G{'jF �®C�`S <br /> 1. NAMFB OF STREETS OR ROADS NEAREST TO OR BOTHPLOTLA PRAN RN—1.�YwI ReNw -to <br /> Z. OUTLINE OF THE MOPF.RTY,Of""OIMFNMNB AND DINO NORTH DIRECTION. J. LOCATION OF HOUSE SEWAGE Dl.q)gAl gYSffM OR PR0106ED <br /> J.STRUCDIMENTURES. <br /> INCLUDIQUTLINFNG <br /> CO LOCATION OF ALL AS FANO AN EXPANSION OF SEWAGE MGMAAL SYSTEMS. <br /> O DRIVEWAYS, <br /> O S. LOCATION OF WFUS WITHIN MOIUB OF ONE HL,MRM FIFTY FT. <br /> STflVCTVREB,INCLVDINO COVERED AREA.SUCH AS PATIOS,DPoVEWAVS,ANO WALXB, <br /> ON THE PROPERTY OR ADJOINING FROPERTV. <br /> DEPARTMENT USE ONLY <br /> APeSvwlbn Aeeaela8 By 'Z 3' <br /> J Mlw <br /> awl In.,nplle„er pa. PM.,P In.P.enm1 By <br /> D.1. <br /> Ow.lnmlkn I..e.ene., <br /> BY <br /> Uwle <br /> Deminwlr. �ovbEd= 5 C-1'�r P_G� L7vLtt< <Nln bCyrTHt�d' <br /> ACCOUNTING ONLY: AID• <br /> FACS <br /> PE CODEC FEE INFO AMOUNT REMITTED CNECKIMA811 RECEIVED BY DATE FEIMIT/SERVICE REQUEST NLMBEII INVOICE <br /> (0851 G� y3.R 1 3 <br /> Pub.Health Sew.-Enviro.173(3/96) - <br />