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• APPLICATION FOR WELLIPUMP PERMIT • <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON. CA 95201.388 <br /> (2091469-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complain in Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELO ,CH OR 9-1115.3 ANO T E ST !DARDS OF SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AGORES6/OR APNF _ql CITY V ` PARCEL SIZE/APNF <br /> OWNER'S NAME ADDRESS RIONEI ! <br /> r / 2 <br /> CONTRACTOR ` c - ADDRESS C' LIC,I L RiONE <br /> SUB CONTRACTOR ADDRESS LIC( RHONE F <br /> TYPE OF WELLIPUMP: �,❑y�NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> SLID J111L��1..-MSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT PAIR ❑ VAMP EXTggCTION WELL■ J <br /> Id / H.P. I f7 DEPTH PUMP bETFT. FIfl6T WATER LEVEL / O <br /> (TYPE OF PUMP) <br /> �/CI I{/ <br /> ❑ OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. A <br /> 13 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION pHA.OF CONDUCTOR CASING D <br /> I-q'OOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yet No CONCRETEPEDESTALBYDRILLFR:❑Yr ON. S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE B <br /> PROPOSED CONSTRUCTIONIOIBWNG 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 /> 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 NMICH <br /> THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING 09 SUBCONTRACTING SIGNATURE CERTIFIES S <br /> THE FOLLOWING: -I CERTIFY THAT IN TIEPERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA. N APPLICANT MUST CA24 M S IN ADVANCE FOR ALL REBURIED IN9PEC)(BN4 AT(20014083{23. COMPLETE DRAWING AT LOWER AREA PROVIDElit. <br /> 9I9,rS X IIAI II TltleO( - Dm v <br /> PLOT PLAN IDra to SPnel Scala 'to <br /> 1. 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, U <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS.PATIOS,DRIVEWAYS,AND WAIKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> S PAY EN7 <br /> Pr-IrERIFF) c-D <br /> L JUN 2 3 1995 <br /> PUBLIC HFA( SERVICES. <br /> ENVIRC)NMFNT 3L HEALTH DIVIc ON <br /> ►I <br /> tbu� <br /> nne- . <br /> DEPARTMENT USE ONLY <br /> APPllcallan AccootM By Dole C A— <br />