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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JO/ I COUNTY PUBLIC HEALTH SERVICES <br /> IL,, E616NMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JOAOUIN ST,STOCKTON,CA 95201-388 <br /> (209)469-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete H Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANONR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDAMIS OF SAN JOAQUIN COUNTY MBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> IBADDRESSIORAPNI 5451 East Harding Way Stockton <br /> CfTY PARCEL BIZE/APNI`.MER-9NAME KJAX Radio Station - FEMA ADDRESS 110 North E1 Dorado St, S,�&Flcton <br /> CONTRACTOR woodward-Clyde Federal Services <br /> ADORES SQV�jPIONF� -Q 88 <br /> JB CONTRACTOR FN PROP P.O. BOX' y <br /> ADOREeSa�r}e ,C-57 (NA)RONEICo� rO <br /> A..A'PE OF WELLIPUMP. ❑NEW WELL ❑REPLACEMENTWELL ❑MONITORING WELL# ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM WMA ❑CROSS{ONNECT REPNR ❑VAMA WRACTION WELL I J <br /> ❑N.❑R.", H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> YPE OF PUMP 0 <br /> ❑OUT-oF.SERVICE WELL ❑GEOPHYSICAL WELL I [1}JOIL BOFUNO S <br /> DESTRUCTION: <br /> INTENDED USE TYPE OF WFLL CON{TgUCTON 6PECIRCATON{ <br /> t)INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL UCAVATION DIA.OF CONDUCTOR CASING A <br /> IDOMESTIC/RVVATE 11GRAVEL PACKIIZE TYPE OF CASING/STEEL/PVC D <br /> LL.1..., DIA.OF WELL CASING D <br /> R101K:/MUNICIPAL 13 DRIVEN DEPTH OF GROUT SEAL 6 Q E SPECIFICATION R <br /> ❑IRRIGATION/AG ❑OTHER GROUTSEALINSTALLMBY_ Tremmie Pipe GROUT BRAND NAME E <br /> kMONITORING GROUT SEAL PUMPED:❑Yr ❑H. CONCRETE PEDESTAL BY DRILLER❑Yr nN $ <br /> rL��.. <br /> 'PROX.DEPTH Q T f LOCKING CHESTER BOX/STOVE RPE S' <br /> L%OMSED CON{TRUCTION/DgWNO METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER Direct Rush <br /> YEMSY CERTIFY THAT I HAVE PREPARED THIS AFRICATION AND THAT THE WUM WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND PROLES AND <br /> :GULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> IIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PENSIONS SUBJECT TO WORXMAN'{COMPENSATION LAWS OF CALIFORNIA.-CONTMCTOWS HIRING OR SUB4ONTMCTING SIGNATURE CENTIMES <br /> VIE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORAMM-S COMPENSATION LAWS OF <br /> CAUM IA.' E APPI C NT MWT C LL Z4 H0 R{IN ADVANCE FOR ALL REQUIRED IN&MTONS AT UE0{1441R ln.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> SI,, X nG. Geologist 3-15-95 - <br /> Bill Loskut ff a D.t. <br /> POT PLAN ID,.w I.Srl.l 6r1. 'to <br /> NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> ter OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE-mNO6M$YSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6.LOCATION OF WELLS WITHIN SAL$ OF N$.ONE HUNDRED FIFTY <br /> FT. <br /> STRUCTUIIES,INCLUDING COVERED AREAS SUCH AS PATIOe,DRIVEWAYS.AND WAl%S. ON THE POPFRTI.OR ADJOINING PROPERTY, <br /> .... ... ... .:. i.... ._. i.. <br /> yl+ e SeAttached Nap <br /> II .. <br /> y DEPARTMENT USE ONLY <br /> ARPIIgtion A WIW BY D.t. Mr <br /> m Impr BY D.t. P P ImIHOtlon BY D.t. <br /> vuetbn Irp.eUon BY <br /> D.t. <br /> V <br /> Comm�b: <br /> WCOMT010 ONLY: AID# FAC# <br /> RE COO- FEE INFO AMOUNT REMITTED CHECUICASH RECEIVED BY DATE PEAMITISE NCE REQUEST NIIA{ER INVOICE <br />