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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> II <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Compkto IB MpHents) <br /> APPLICATION 19 HERE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AN01GR INSTALL THE WORK OESCRIBEO,TFI19 APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> t. JOAGUIN COUNTY DEVELOPMENT�TIITLLE�E''.CHAPTER,,{9�-1 115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVIRtON, ,y /� <br /> JOB ADDRRESSIOR A//P��NII cc Uri' S e'� crry s-k"x,�� PARCEL 9IZVAPN/ ! Jr,,�, U L v <br /> OWNER'S NAME LJI,'Ir��,�lVWL 1 L �(�kA AGGRESS I CT�Or� tr�Y�ry C�1yf '-'i/c _PHONE/ WUJ'(�� •.7 <br /> CONTRACTOR 1IC{-Ar- •Ct-SING, =i�-^� ZL. ADVRE88 410�(�. L7 Yum �+ LIC! PHONES J.TT`p�L)C <br /> AVBCONTRACTOR MlTC-YW � 1 1L�L - - --ADORE88 po�^•' 2�n, LIG <br /> TYPE OF WELLIPUMP;X=TALLATtON <br /> WELL ❑ REPLACEMENT WELL �MONrTORING WELL l © OTHER <br /> ❑ WELL SYSTEM REPAIR ❑ CRO89-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 J <br /> ❑New❑Repalr H.P. .DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) , <br /> ❑ OUT-0E-BERVICE WEL! ❑ GEOPHYSICAL WELL/ ❑ SOIL SORINO _ $ <br /> ❑OESTRUCTION: - <br /> INTENDED USE TYPE OF WQ.L CONSTRUCTION IFECI"CAT1ON0�+ I U . A <br /> ❑ INMSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION C3 DIA,OF CONDUCTOR CASINO N iA O <br /> ❑ DOMESTM11PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINOISTEELIPVC j L O(A-OF WELL CASFNOC_. D' <br /> ❑ PUBUC/MUNICtPAL ❑DRIVEN DEPTH OF GROUT SEAL 3 SPECIFICATION �.,.,40 1�-,' A <br /> UT BRAND NAME E <br /> MOIMGROUT SEAL PUMPED: i Yr ❑Ne O 't OTHER INSTALLED O 1 ` CO <br /> RONRORING Y CONCRETE PEDESTAL BRILL R{`❑ w tgKYa S <br /> 4, APPIOX.DEPTH LOCKING CHESTER BOXIBTOVE PIPE 5 <br /> - PROPOSED CONSTRUCTOO NlMtlLLINO METHOD: MUD ROTARY AIR ROTARY AUGER V _CABLE OTHER - <br />`I <br />{ I HMOY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITk GAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT•8 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERPORMANCE OF THE WORK FOR WHICH <br /> I IRIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERGOLAS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR-9 HIRING OR SUR-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN TILE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORgWAN'S COMPENSATION LAWS OF <br /> CALFORNIA.' THE APPLICANT MUST CALL 24 HOUAS IN ADVANCE FOR ALL AFOUMCD INSPECTIONS AT 1200148111-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. cy <br /> f�€ Stoned X Tltte_ .� J+��s P` Do. �/1! !g s <br /> l •T PLAN O&W to 50.1e1$--1• 'to ^ <br /> 1. NAMES OF STREETS OR GOADS NEAREST TO OR 13OUNDIPM THE PPIOPERTY, 4. LOCATION OF HOUSe SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> j 2. OUTLINE OF THE PMPERfY,GIVING DIMENSIONS AND NORTH DIMCMN. EXPANSION OF SEWAGE 040MOAL SYSTEMS. <br /> 4 3. OIMENMONEO OUTLINES AND LOCATION OF ALL EXIST"AND PAOPOBEO S. LOCATION OF WELL Wrn*N RAMtw OC NE HUNDRED FIFTY FT. <br /> o W <br /> S <br /> z � <br /> IS. <br /> A oZ �• U 21 Z ..:.-. <br /> -.� ..�-...•...Pray. - x - - <br /> � � vel• `3' L-�a'�-a' .. -: .,.... <br /> Ota..e Inapeetle..B► � �''� Date <br /> Pump Inapeetlon By Det* <br /> Deetnntlen 1n pmtlon By <br /> Date <br /> ca-M&A.: '" <br />�I ACCOLNITINO ONLY; A109 FACN <br /> PE CODES FEE INFO AMOUNT tIEMITTEO CHECK//CASH RECEIVED BY DATE Pff"TIs"MCE REOVEET NUIWBIR INVOICE <br /> 0 , IC <br /> Pub Health Serv.-Enviro.173(1197) <br /> c <br />