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SAPPLICATION FOR WELLIPUMP PERMIT <br /> AN JOAOUIN COUNTY PUBLIC HEALTH SERVIL <br /> ENVIRONMENTAL HEALTH DIVISION <br /> t P•O, BOX 386:,304 EAST WEBER AVENUE,STOCKTON, CA 9S2DI388 <br /> 1209) 469-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I F <br /> AF TICATION IB HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A FfI1MIT TO CONSTRUCTANO/OR INSTALL THE WORK DESCRIBED.THIS AFPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115,3 AND FIR STANDARDS OF SAN JOAQUIN COUNTY FURLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> �j <br /> JOB ADDRESSOR AMI Q a ' 6/a•3 PauFfc .5n6r�/'✓�I 9�Y6-/9 <br /> o'`.� /l CITI o y PARCEL SIZEIAPNI o <br /> ONMER'S NAME [/'\'V.I ]yy1��L (AL IT _ r�� AIMRF.SA_(/nE}OI Oo 119,6, y-d yq(, <br /> CONTRACTOR FIIAA.V ILLTJ�r yiy\C. AOORfReSro Box aSY sa�nE+o <br /> ��,� rl ll�na O[Z-'RR '/ � N<• / RIDHE.7o[��y'J <br /> FUBCONTRACTOR "' <br /> ADDRESS YjV []pNGR(,11A4t��E-FC�'/6S— FHONE/•JAo JIJ'J� <br /> TYPE OF WFL4AIMP: lrI NEW WELL ❑ ME CEMFNt WELL MONITORING WELL I MW-6�Mw-7 ❑ OTHER <br /> ❑ INSTALUTION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR WE <br /> EXTRACTION LL <br /> ❑OF�MMP) New❑RnP.N N.P. <br /> RVDEPTH PUMP SET—FT. FIRST WATER LEVEL <br /> ❑ OUT-OF-SERVICE WELL ❑ GEGRIYAICAL WELL I ❑ WIL BORING O <br /> DESTRUCTION- A <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIRCATIONS6 d <br /> ❑ INDUSTRIAL ❑OFENSOTTOM OIT DIA.OF CONDUCTOR CASINO_ N/r' A <br /> py DIA.OF WELL EXCAVATION <br /> ❑ DOMFSTICRRAVATE Ip1 GRAVEL PACK/SIZ �, Sfg' TYFF OF CASINWSTFFTF ,— RV DIA.OF CONDUCTOR <br /> ❑ UBUCSAUNICIPAL ❑DRIVEN OEFTII OF GROUT SEAL' — O r Sck YO q <br /> 1,,.,. "CIFICATION <br /> ❑ MONITTWNG ❑OTHER GROUT SEAL WSTALLED BY DPIIUY OROUT BRAND NAME ��p{ <br /> MONITORING GROUT SEAL NMFEO! ❑Yw. ❑Nn CONCRETE FEOESTAL SY DROMER:W Yr ON. S <br /> APPROX.DEPTH LOCKING CHF"FR BO%/STOVE RIFE <br /> MOMSFD CONSTRUCDONRXAlLUMO METNOO; MUD ROTARYS <br /> AIR UTAFry AUGER CABLE <br /> OTHER <br /> I HERERY CERTIFY THAT I HAVE PREPARED THIS A-1—AFRI THAT THE WGR(WILL RE DONE M ACCORDANCE WITH BAN JOAOUIN COUNTY <br /> nEGULATIO HP OF THE BAN JOAOUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLO'MNG:'1 CERTIFY THAT IN THE ARPERfOHFMA CE OFS,STATE THE <br /> AND UREA AND <br /> THIS FEnMIT M ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENgTOMHIRING WgUK FOR CERTIFIES <br /> THE FOLLOWING; •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS UWfl U CALIFORNIA.*CALIFORNIA• CONTRA RONS SUBJECT <br /> OR WORKMRACTINO SIGNATURE LLAWS OF <br /> PERMIT IB ISSUED.I SHALL EMPLOY RREONS AURJECT TO WORKMAN'S COMFEHSAROM LAWS OF <br /> CALIFORNIA <br /> '��l THE APRICANT MUST CALL}A HOURS In ADVANCE FOR ALL BEOUMEO/IJM5R,IC�TI�ON}S AT 12001 AA�EA�A�}}/, COMIIETE pUVJINO AS LOWER AREA FROVIOEO. <br /> TIO �p <br /> 91SM% //n/ r/(//GN r{�!!({Tl u(/C�F <br /> ••MM �O D.ew <br /> ROT FUN M—w An..,Sn.M --G <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDIHO DIE FROIERTY. t. LOCATION OF HOUSE SEWAGE OIflPOS <br /> 2. OUTLINE OF THE PROPERTY,OMNO DIMENSIONS AND CRT"DIRECTION. AL SYSTEM On FGOTOAEO <br /> G. DIMENSIONED OVTLIMM AND LOCATION OF ALL EXISTING AND FRRPoSEDEXPANSION OF SEWAGE DISOOSAL SYSTEMS. <br /> STRUCTURED,INCLUDINGCOVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WAUKB. A. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOnED FIFTY FT. <br /> ON THE PROF1ATY OR ADJOININO PROPERTY, <br /> �I <br /> DEPARTMENT USE ONLY �} � 'TT <br /> AR,11. 1I A—.,M Br��(" DM. 1 •3 ' //y '/ Are. <br /> Or.N Imgmllen ar DMs Pune Ir 0.11—By <br /> O.I. <br /> Dw.ul�nnnn I,.nwwnen ev <br /> cnm wn.:�(�C55 Q�(LE2nLa l7t J`t5 Y12y 1JN o <br /> D.I. <br /> vLcSl4�C (02�.�1 e t4 AtrIoL-rk 0-dlulaA 7:7. <br /> ZI97� <br /> 1 <br /> ACCOUNTING ON, ATDI <br /> FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXIICA9" I RECEIVED BY DATE <br /> FDSAIT/Sp11RCE REQUEST NUNSRI INVOICE <br /> 3 0Y7 1 <br /> Pub.Health Serv.-Enviro.173(3/96) <br />