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C-d <br /> ... '= <br /> APPLICATION FOR WEL.L,IPUMP PERMIT <br /> SAN .IOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ,oAyliMENT ENVIRONMENTAL HEALTH DIVISION <br /> � £ 304 EAST WEBER AVENUE, STOCKTON, CA 96202 <br /> AUG 2 5 X998 (2019) ass�a2o <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> SAN (CatnplBN ti Trlpflntsl l SAN <br /> APR,ICA710FRf11SFAM �Crid�JOAOVIN COUWrY FOR A PERMIT TO CONSTRUCT AHWOR INSTALL.THE WOW lDEBCMWO-TMIS APPLICATION 10 MADE IN COMPLIANCE Wfri <br /> ASAN JC?nOUIN C7unlTl <br /> JOAOUf6hY @1�1IQ 4@ �L�r�(1.�L lVIyEC i 9-111 B.3 ANO TH`E�SrAHORAms OF SAN JOAQUIN COUHCIY PUBLIC tH�.EAALT14 SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AtOQAEB$M7R APHf <br /> ZI&V ��T cY y C�'v✓, PARCEL WWAPNf ` <br /> ^ `i l,( O ' <br /> OWWR°S NAME 6�Yi S.+�/l I 1rMD VU e- AOOREBa ZB� ` <br /> �5�$pGi4 �1/1l• AODRESS Z60 k:(5 �. Ucf PHONE r <br /> CONTRACTOR [n f ( <br /> RUB CONTRACTOR ]CTOR V 'V V v''iki AGGRESS rte" `�i l��- °� L1Cf Pf10NE r�� 77'T•�'I.J{N <br /> OF MF" Se—WELL WELL ❑ REFtAcEMENT wELL XMONIT9 of WELL f I ❑ OTHER . <br /> ❑ <br /> INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR -(3 VAPOR EXTRACMN WELL f J <br /> ❑How❑Rw.* H.F. DEFT"PUMP SET FT. FIRST WATER LEVEL 4 . <br /> (TYPE OF PUMPI <br /> ❑ OVi4FSERVICE WELL ❑ GEOPHYSICAL WELL f ❑ SOR BvPoNG 9 . <br /> ©DESTRUCTION- <br /> INTENDED USE TYPE OF WELL _ CONs'fRUCTTON APECWCAT1ONs 8 .fJ A <br /> ❑ tHOUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 0 1 OIA.OF CONDUCTOR CASINO <br /> ❑ OOMES7ICM MVATE ❑ RAVEL FACXlBRE TYPE OF CASINGAITL'ELRVC C L GIA.OF WELL CASINO' ZV D <br /> F ❑ PUBLi MUNIMPAL ❑DRIVEN DEPTH OF GROUT SEAL O _ SPECIFICATION 5cr <br /> 13MOATOONIAO ❑OTHER OROUr SEAL INSTALLED SY �M– Irk'� �-_. GROUT BRAND NAMETLLR:AO—n4--./UAB`* E <br /> WI.AOHRORINQ GROUT SEAL PUMPED:0 Y. ❑N. CONCRETE PEDESTAL BY OWLLER❑Y« ON. s <br /> APPROX.DEPTH ( "'� � LOCI m CHESTER BOXISTOVE PIPE' S <br /> PROFosm CONSTRUC710NfOPIILNG METHOD: MVD ROTARY AIR ROTARY AUGER" X_– CABLE OTM.l <br /> 1 HVWBY CERTIFY THAT 1 HAVE PREPARED THIS APPMATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. NOW OWNER OR LICENSED AGENT'S SIGNATURE CEHr1P1ES THE FOLLONSIIti '1 CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHICH <br /> TWO PfNk4ff IS ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMMMISATIQN LAWS OF CAUFORWA.' CONTRACTOR'S HIIIRG OR SUSCOIffRACT"M SIGNATVRE CERTIFRS <br /> THE FOLLOWING. 'I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH TRIS PERMIT IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WOM MAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS M ADVANCE FWI.ALL REGMED INSPECTIONS AT 120,)400,,,23. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> gW,.ed X� .LJInAn1� �� Thh �L I T 1 .Vl.LLGI.IJL/ _. Doti <br /> PLOT FLAN IDe~t.80etel Sam -to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.GIVNM OIMENSIONS ANF)NORTH Ol TION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXIBTBG AND FItOPOBED s. LOCATION OF WELLS mrmm RADIUS OF ONE HUNWtED FIFTY FT. . <br /> STRUCTURED,04CLVENNO COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WILLXB_ Oli_THF Pr.mmi nu an re<ttetn mnnc.r.v <br /> s <br /> W <br /> W p w W <br /> a w42n... .. . <br /> . rc7X Z Z 0: <br /> i ' Z I r 0_ J LL O <br /> _.. <br /> vjomnm <br /> ulmvva <br /> OvAMM41NT USE ONLY - <br /> Ap.Srrtlen Ae~ed Sr Det. <br /> Oreul(.uPerSen D1r�� .iA Orem sloop Itu.�elen By Ort• <br /> O..en'ct1.n I-Mwtl.n Br veto <br /> ACCOUNTING ONLY: Aloo FACT F <br /> PE C00ES FEE INFO AMOURK REMITTED? CHECK/!CASH RECEIVED BY OAT FERIMITISERVICE REQUEST NUMBER INVOICE <br /> S <br /> Pub Health Serv.-Enviro.173(1197) <br />