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APPLICATION FOR WELLIPUMP PERMIT <br /> *AN JOAOUIN COUNTY PUBLIC HEALTH SERO <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAOUIN STT, STOCKTON, CA 95201-388 <br /> (209) 488-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPM(E�NTT TITTLE,CHH'A.FrrER 9-1115.3 AND STANDARDS OF SAN JOAQUIN COUNTNTYYPUBLIC H-TEA.L�THI SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APP�NO!13q <br /> 3 1 / 6, I:j�-EF� r'j T_ �]� CITY <br /> I_.L,) 1VC/A'I✓I v C� PARCEL SIZE/APN2 <br /> OWNER'S NAME / V �1_ ADDRESS ✓CAM-1 E /'1 PHONE 0 <br /> CONTRACTOR l �i�s �ffhl (L-F21�� J.{oC.i ADDRESS �lT LIC7 0 NE 12L 772 <br /> L <br /> / Cil <br /> SUBCONTRACTOR A IJk— ADDRESS UCI PHONE# II <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLI <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS&CONNECT REPAIR VAPOR EXTRACTION WELL♦ <br /> 13New❑Refel, N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL G <br /> ITVPE OF POMP( �t'y/ f <br /> 11OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I Tj� SOIL BORING �` g <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATIONS /I A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D <br /> ❑ PUBLICMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEALEZIM�BASPECIFICATION n R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLD BV_ GROUT BRAND NAME L� E T r E <br /> 11 MONITORING GROUT REAL POMPEDSV(r ❑Ne CONCRETE PEDESTAL BY DRILLER:❑ r�No S <br /> APPROX.DEPTH /(� -15 LOCKING CHESTER BOX/STOVE PIPE__ S.- <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> AEGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS BUWECT TO WORKMAN'{COMPENSATION LAWS OF <br /> CALIFORNIA.• T E APPLICANT MUST CALL 1! ADV N E R ALL REOU1RED INy/SPP�ECTIO,N/&AT 12091��/4/M//8L3442233.�COOMPLLETE/D�RAWING AT LOWER AREA PROVIDED. <br /> 810 Title I/y4 w I-f F P 1'IPS/- 1 V E t`_ Dete <br /> • PLOT PLAN(Drew to S .)Sul--_•to 3 o�F a— , <br /> 7. 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,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES 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 WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> i_ <br /> ry <br /> 6.FoT ttN(CA-�- 7;1R PO=I z <br /> LI <br /> CtrJT <br /> �� WA^�ELS� (A/ArIEIIW�C LI011SJ1/rc(7 <br /> L� <br /> MEA E; " <br /> - ----C�eP-TFvO£ <br /> JI h ex <br />