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APPLICATION FOR WELLIPUMP PERMI <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEAMS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 398, 446 N. SAN JOAQUIN ST, STOCKTON, CA 96201.390 <br /> (2091469-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBmpl4b In TdplkAlll <br /> APPLICATION IB HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORT(DESCRIBED.THIN APPUCATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8 1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTYPUBLICHEEA�L`THI BEO/V�ICEB,ENVIRONMENTAL HEALTH DIVISION. �I�I�/� <br /> JOB AODRE88JOR APN�/µ3A3 E. RZE ryft�T- T_ CITY ., 1 aJGE.�/y(V C If- PARCEL OI2E/APNI/q( 5 -?W(E D <br /> OWNER'S NAME I /V L&- n l t ADDRESS 'K_N(71'Z f.�� �,A /'1 PHONE IS[�(J <br /> CONTRACTOR ( V /�.S /L,CryFJI (�- LI�Iry Jy I("i ADDRESS AlI ��IUCI O- -45 PbNE I3q 7771()1 <br /> BUB CONTRACTOR /V /1 ADDRESS LACI PHONE/ <br /> TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I � <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS&CONNECT REPAIR R EXTRACTION WELL/ J <br /> RYPE OF PVMPI a <br /> ❑Naw❑Falr H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL O <br /> ❑ OUT-OF-NERVICE WELL ❑ GEOPHYSICAL WELL I •`r- SOIL BORING 7� g <br /> IJDESTRUCTION: <br /> NTENpEO SE TYPE OF WtUCONSTRUCTION SPECIFICATIONS PI A <br /> 11 INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION_ DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMEWIC/ VATE ❑GRAVEL PACK/SIZE TYPE OF CARING/STEEUPVC_.� DIA.OF WELL CASINO D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION g <br /> ❑ IRRIGATION/AG ❑OTHER GROUT BEAL INSTALL D By r 1 I�-4WV— GROUT BRAND NAME 6 r E - <br /> ❑ MONITORING L GROUT BEAL PUMPOt . ❑Na l CONCRETE PEDESTAL BY DRILLER:❑ �N. S <br /> APPRp%.DEPT" /U I �1 Fit T LOCKING CHESTER BO,XjnoVE\PPJE— ` S.\ <br /> PROPOSED CONSTRUCTIONIDIYWNG METHOD. MUD ROTARY AIR ROTARY AUGER^�CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIN APPLICATION AND THAT THE WON(WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULEB AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'N SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS BUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING• '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' T E APPLICANT MUST CALL 2 P UP 11 AOV N E R ALL REOUIRED INSPECTIONS <br /> BIN I INSPECTIONS AT <br /> 1201H4NJ 22. COOMPETE DRAWING AT LOWER AREA P/7-D;TRI. Rp4wlf ' /YV" - /lg— D.I. <br /> / <br /> POT PLAN IDr.w Io So.1.1 N I. •Io 30o f 1- <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAU(S. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> kf2q�:- RII <br /> tcrtNccht- 7IRR?� =1 21 <br /> xcnrm rnn <br /> WO0,11�E WARle'tfWSC �� 1�1�1 � ?Jv�� <br /> A' <br /> 41 <br /> E E �R d Z <br /> ��rl<JtF <br /> U EA <br />