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APPLICATION FOR WELLIPUMP PERMIT <br /> JAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OIVISIOH <br /> RO,BOX 386,904 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209)468.3420 <br /> pDD•REMMARLE PEWIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Momp62lt iR Trbl•1>•mIt) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRTII SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS rOF SAN JOAQUIN COUNTY TP-UBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOS ADDRESSOR AP� S PAL I F 6L (j a S -225K M'P;20� &0510 CITIryC(�. /(T[' K4 On PARCEL SIZE/ARNI <br /> AM <br /> OWNER'S NE. tAl clRVVI .'ln Y1f_be L— /� ADDRESS Z�r,`p Nt_[��� fj J)r� STr,(KIONEI <br /> COM RACTOR�I_dA&jac C.P(?C nyi:y,�_P/j Tom-' 14, ADORES e �p03 ��/ �r,h/., ua-7 <br /> l' �uc,�Sc,CZ7 PIONEI`)S{, OL(.T1 <br /> SUS CONTRACTOR�[1 '�J-< #—jaiy fL Y l ADDRESS N ITC/ �pH"_:r, <br /> � �3: <br /> TYPE OF WELVPVMP; NEW WELL ❑REPLACEMENT WELL N+O NTORING WELL t � �^ y�(�HE <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR CJ <br /> El New❑Ftp.,, H.P. VAPOR EXTRACTION WELL F­,-3 ,/ <br /> RYPf OF PUMP) DEPTH PUMP SET FT. FIRST WATER LEVEL 4 IC O <br /> Dry C c ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL, ❑ SOIL BORING 6 <br /> DESTRUCTION: rT//1 /� (- C-Q Q V I <br /> INTENDED U&E TYPE OF WELL CONtTR1/CTIUX 6PECIFICATIOM� A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑OOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC VIA.OF WELL CASINO O <br /> ❑PUSUCRAUNFCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONITORING GROUT SEAL PUMPED:❑Yw [IN, CONCRETE PEDESTAL BY DRILLER:❑Y.. ❑No 5 <br /> APPROX.DEPTH LOCKING CHESTER BOX/tITOVE PIPE S <br /> PROPOSED CONETRMTION/OIELUNO METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE CAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'i CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IC ISSUED,1 SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP SAFION LAWS OF CALIFORNIA.'COMRACTOR'S HIRNG OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS IS6VEo,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPD702ATION LAWS OF <br /> CAUFORMA.' THE/lIWJCA T MUST CALL 7 /IOL/RS IN ADVAN I.`EQ,FOR ALL REOUR'O INSP�CTTIIONS AT 12")400J/23.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> SI.—IX •_!tM��_ li'1— TIB. S44F-- C?-L'n/✓5/Si D.,. //—o S�G <br /> PLOT PLAN IDt.w to Scr.l S-1. 'to <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. !.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR pMMSED <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 /> �j tAK flow <br /> IL <br /> // �v- Ew M TM ViE ONLY f 'l <br /> ApPSc.Uen Ace.PtrP PLY-.._ - I DO. <br /> _-_t''jJf'_—�J A­ <br /> 0'..IMP«tion BT D.t. P— In•«tion B <br /> D.t. <br /> VaUn.tinn Tr�P«rlen 9, I not <br /> Comm.. <br /> ACCOVNTINQ ONLY: ATO! FAC! 3 <br /> PE CODES FEE INFO AMOUNT R0.STTE0 CHECK//CASH RECEIVED BY DATE PUMTI$MVICE REQUEST NUMBER INVOICE <br /> 2 vt L1 7 <br /> Pub.Health Serv.-Enviro.173(3/96) <br />