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APPLICATION FOR WELLIPUMP PERMIT <br /> *%rSAN JOAQUIN COUNTY PUBLIC NEALTR SERV..fs <br /> ENVIRONMENTAL HEALTR DIVISION <br /> P.O. E�f}X 3$8, EAST`NEE3ER AVENUE, STOCKT ON,CA Mol vAS <br /> (208) 48$-3420 <br /> ItOtf•BEFUN�ABLE PERMIT EXPIRES I YEAH NO HATE issuEO1 <br /> APPLICATION IS NEVE BY MAIC TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO Cf NSTRUCCTlou iANDIOR INSTALL THE WORK DESCRIBED.TNIS ApPLICATj3N IS MADE 1N <br /> JOAQUIN COUNTY DEVELOPMENT TITLCHAPTER$-11155.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, COMPLIANCE-WITH SAN <br /> JOB ADDRESSIDR APNI l fia sS 1- CITY d_ ; HEALTH DIVISION. <br /> Imn <br /> OWNER'S NAMEt ♦ t i { PARCEL SIZV PN# Q t- �t Q <br /> {" ADDRESS A 3 1 LET C ,,j I NE! 1 - O i?2 i <br /> CONIRACTO 1 W IC `t UA IAWA C, L� 0�( f <br /> �["� ADDRESS UCi [q#1t 8 <br /> < SUB CONTRACTOR__ 1 X11 {0 y8 lh d b Acnn. �C l <br /> am— i - CICt"�IvB PHONE <br /> TYPE OFWELLtpUMP. ❑IEW WELL O AEPLACEMENT WELL rtD MONITORING WELL OTHER <br /> INSTALLATION �WELL SYSTEM REPAIR !_I CROSSCONNECT REPAIR ��+yy <br /> G.,i.VAPOR EXTRACTItON WELL# J <br /> New 13R,* H.P. DEPTH PUMP SET FT: ' <br /> (TYPE OF.PUMP) IG---� �-t FIRST <br /> ER LEVEL D: <br /> 11 <br /> j�I tT <br /> I...I OUT-OF•SERVICE WELL LJ GEOPHYSICAL WELL II SOIL BORING a <br /> .W DESTRUCTION; - - - -- <br /> NTENDED USE TYPE OF WELL <br /> -7 :CON$TRUGTION$P€GIFGCAYION$ i4 <br /> 0 INDUSTRIAL Q OPEN BOTTOM DIA.OF WELL EXCAVATION <br /> L.J DOMESTICIPRIVATE 13 amVET,PACKMZE DIA.OF CONDUCTOR CASING O: <br /> tT-^�IG TYPE OF C gSING16TEEtlPYC DIA.OF WELL cAme <br /> U PUSUCIMUNLCIPAL L_J DRIVEN DEPTH OF GROUT SEAL <br /> SPECIFICATION <br /> R' <br /> C+ry�R) I MONITORING <br /> Q OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> I.! MONITQRINB �I----tO :E <br /> GROUT SEAL PUMPED: 0 Yee Q No CONCRETE PEDESTAL BYbRIL FR:©Yaa [3N* s <br /> APPROk:OtrPTH LOCKING CHESTER aOX19TOVE PIPE <br /> 1'RRPt!$ED iCONBT"vC1'NDwwjl LUNG 1 t,pRID: MUD ROTARY �w ARIL ROTARY AUGER CABLE OTIfER g�`IY-{S v .. <br /> I HE9EBY CERTIFY TIGAT!HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCOROANCE vMH SAN JGAOLRN COUNTY-ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE JOAQUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING.,'I CERTIFY THAT IN THE PERFFLRMANCE OF THIEWOW FOR WHICH <br /> THIS FERRATE GS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR`S HIFUNO OR SU"01 TRRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSON74 SUBJECT TO W6RlDNAN'#COINPEl4>1AT10N LAWS OF <br /> CALIFORNIA.' THEA CANT MUST CALL 24 HOURS W ADVANCE FOR ALL REQUIRED IN$AMTIONi T I"01(�4h48,4428j` COMPLETE WING AT LOWER:AREA PROVIDED. <br /> SlQnsd X `�..:3� A 1YJ Z-ICII Date <br /> PLOT PLAN(Draw to Soots)Scale "tb <br /> T. NAMES OF STREET R RO DS NEAREST TO OR.BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL BYSTEM:ORPRQPOS£D <br /> 2. OUTLINE OF THE PRO . GIVING DIMENSIONS ANDS NORTH DIRECTION, EXPANSION Of SEWAGE DISPOSAL SYSTEMS. <br /> 5: DIMENSIONED OUTLINFS ANO:DCATION OF ALL EXISTING AND PROPOSED <br /> .. B. LOCATION OF WELLS WITHIN RADRIS.IOFOFlE HtiNlti P`IFTY F?. <br /> STRUCTURES,INCLUDING COVERED AgFAB:OWN AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> i <br /> y <br /> DSPMTMENT:UBE ONLY <br /> Acpltoatbn Accepted By. Data ` 7 Mea, <br /> Grout Inspection by Lista.. Pump Inspection BY Data, <br /> Usatttwito rInsooctlon.Bt1::...............:..........:. ...:..:................... . < Date <br /> Comments,. <br /> ACCOUNTING ONLY: AID# FACN. <br /> PIE CODES FEE INFO AMOUNT RErAITTEn CHECKOICASH RECEIVED BY DATE: PERMITI$ERVICE REQUEST NUMBER INVOICE <br /> 35p X113, ty �, ; ,, DIC?$Io+ <br />