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APPLICATION FOR WELLIPUMP PERMIT • PAYMENT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERr., S RECEIVED <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 9mis8eF E K ?0 1496 <br /> (209)466.3420 SAN A;,' L,1,N C6UNTY <br /> PUBLIC HEALTH bER`JICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH DIVISION <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 DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY <br /> -PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/On APN/ 7S {� M ` f ✓/ 1` CITY!r) [I PARCEL SIZELIAPN/2S—Z q0-0 I <br /> OWNER'S NAME e-'1� 1S F't.'Ff l t/t M / ! DRESS N Feely l /� I[ gi?-F4 LdJAdLiNONE I&.0sw'4a� <br /> ConsN1 ran <br /> ae"vftk seR rlv1/i 1 / ^ It, <br /> ! SLG ADDRESS ITfy �L�yL/L S'S111TY( C/�LIc♦ PHONE4(7/�.f3Z-fo"L <br /> —IrDCONTRACTOR V i Y� b1( t.4 p�{ ADDRESS T11 RD e10 VIfji 1+ ­102:21 D G7�-.owI C7 77zfIf <br /> TYPE OF WELUPIMP: ❑NEW WELL ❑REPLACEMENT WELL Ip MONITORING WELL/ 7. R, ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELLS_ <br /> ❑New❑Rep.lr H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O <br /> (TYPE OF PIMP <br /> ❑OUT-0F-SERVICE WELL ❑GEOPHYSICAL WELL/ ❑ SOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS o/I A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM al DIA.OF WELL EXCAVATION S DIA.OF CONDUCTOR CASINO WT] D <br /> ❑DOMESTIC/PRIVATE ®GRAVEL PACKISIZE 3 .s<..d TYPE OF CASING/STEEL/PVC P V(- DIA.OF WELL CASINO Z 11 O <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL /1 SPECIFICATION R <br /> ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY Tfth1 L GROUT BRAND NAME E <br /> PMONITORING -1 /) / C i GROUT SEAL PUMPED:®Y.. ❑No CONCRETE PEDESTAL BY DRILLER❑Y� [IN* S <br /> APPROX.DEPTH /- 0 25 1 l @ y`� LOCKING CHESTER BOXISTOVE RPE S <br /> PROPOSED CONSTRUCTIONIDNWNG METHOD: MUD ROTARY AIR ROTARY__AUGER CMLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND <br /> RULES AND <br /> REGULATIONS 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 /> THIS PERMIT IS ISSUED,1 SMALL NOT EMPLOY PERSONS SUBJECT 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 WORK FOR WHICH THIS PERMIT is ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'.COMPFMaAT10N LAWS OF <br /> CALIFORNIA.' Tye/1PIUCIyJT iT ALL 2!NOUM IN ADVANCE FOn ALL REOlM1ED INSKCTION..AT I .)4gJ4211.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> slpnw x /Y/JjYY//•✓V r/Kl/ Tltl.C] lS7 �Ntt/rcq k c ta!a//od D.t. 2 /S- <br /> PLOT PUN(Dr.w to SW.)Se.l. 'to <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL BYSTEM 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 /> li <br /> DEPARTMENT USE ONLY �.}-,��} ��/'�) (/ <br /> ApPIle.tion Accepted BY�,/� ,. .e.n D.te '� `� L /J� Arr <br /> Great Impeotlon BY �!1` //�-�+--ZfLJ ✓7iLI D.t. J Pump In.p.etlen BY Det. <br /> D—-fl-lon Impeetlon BY D.t. <br /> Comment.: ' <br /> ACCOUNT.ND ONLY: AID/ FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKIICASH RECEIVED BY DATE PERMITIeEAVICE REQUEST NLIINSBI INVOICE <br />