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—� APPLICATION FOR WELL/PUMP PERMIT <br /> SAN*QUIN COUNTY PUBLIC HEALTH SEES <br /> NVIRONMENTAL HEALTH DIVISION Cos <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED alsj ORIGINAL <br /> APPLICATIONIS HERE BY MADE TO THE SAN JOAGU(N COUNTY FOR A PERMIT TO CONST UCTIAllMBI INSTALL THE WORK DESCRIBED.THIS APPLICATION 1S MADE IN COMPLIANCE WITII SAN <br /> JOAQUIN COUNTY DEVELOPMENT TI/TLE:CHAPTER/9-1115/.3 AND THE STANDARDS OF SAN JOAQUIN <br /> R ,( DP 1A7ia I(4- F r�DW AODRE6B_oF.C,.,OU�NZ7CrTA�YPUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMya/6O,10yRNJOB AOOMSS/on APN8jl!' / -CON <br /> OWER'S NAMEt)r.p Cete, PARCELa1ZEANlCITY <br /> /40pIIWGIS <br /> /u <br /> ;19,16 <br /> g <br /> RIONEf S/0'6S2'YdaO <br /> CONTRACTOR <br /> nn T (1 ADDRESS IJCI PHONE I <br /> RUB CONTRACTOP 9��"LL10 1A/-S'�u T P OWG d� <br /> ADORE68/NQ/*/rJT CA 9'/J63 IPHONE 1. •,3/S•$� <br /> TYPE OF W UJPGMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> ❑New❑RepeL H.P. <br /> (TYPE OF PUMPI DEPTH PUMP SET_FT, FIRST WATER LEVELEl _ <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ® EVIL BONNO O <br /> DESTRUCTION: <br /> B <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL 13 OPEN BOTTOM � A <br /> DIA.OF WELL EXCAVATION_ -Lwn JTPS VIA.OF CONDUCTOR CASINO_ AJ�� 0 <br /> ❑ DU LLCM NICIP TS ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEVPVC A/IF7 DIA.OF WELL CASINO_ // Al�,q D <br /> ❑ UIGATIONICIPAI 11 DRIVEN DEPTH OF GROUT SEAL �•G6u1 d04jf'/n SPECIFICATION..CI�i..<wIr- Y,/,oetL <br /> ❑ MONITORING ®OTHER ln:li�/ B <br /> GROUT SEAL INSTALLED BY00)A)1-/CLL fO/"• GROUT BRAND NAME_ N�/.J <br /> ❑ RONITOWNG BMW SEAL PUMPED: ®Yee [I No CONCRETEPEDESTALBYDRILLE,❑Y.e (IN. A//J1 5 <br /> APPROX.DEPTH LOCKING CHESTER ROXIWOVE PPE All& <br /> PROPOSED CON11TAM"ONA)1ILUN0 METHOD: MUD VOTARY AIR ROTARY <br /> AUGER CABLE OTHER OlY IC �uSI� <br /> 1 HEREBY CERTIFY TN-T I HAVE PNtvA U THIS APPJCATION AND THAT THE%YGM WILL BE DONE IN ACCORDANCE WITH SAN JOAOVIN COUNTY OPDINANCEB.-TATE LAWS.ANO RULES ANO <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PEWOR MANCE OF THE WOOL FPR MICH <br /> TIES PERMIT IS ISSUED,;SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR MICH THIS PERMIT IB ISSUED,1 SHALL EMPOY PERSONS SUBJECT TO WOggAAN•S COMPENSATION LAWS of <br /> CALIFORNIA.- THE APPUCARTT�MUST CAµZI HOURS IN ADVANCE FOR ALL REGMED IINS/PECTIONS AT(M l;SHALL . COMPETE ONS SUB AT LOWER AREA PROVIDED. <br /> eivrredx /w.�.�•�- //i _JJ/L/�J �e/(, rnl. ,]i T'C �r•o iPrT /ya n�gaP/^ 7%�9� <br /> POT RAN(N. to Soeel 6e.1. •to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR NOUN DING THE PROPERTY, <br /> S. DIMENSIONED <br /> OF THE PROPERTY.AN GIVING ION OF ALL AND NORTH DIRECTION. 4. LOCATION OF NOVBF SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 3.STRUCTURES, <br /> OUTLINES AND LOCATION OF ALL AS <br /> NO AND PROPOSED EXPANSION OF BELLS 'H IN RADIUS A SOF ON. <br /> STRUCTURES,INCWOING COVERED APFAB 6VCH AB PATIOS,DRIVEWAYS,AND WALKS, -. LOCATION OF WELLS WITHIN INGp, OF ONE HUNDRED FIFTY FT. <br /> /�/ ON THE PROPERTY on ADJOINING PIIORRTY, <br /> ( _ J Rp f�LLaC�1eo(. <br /> 1. <br /> ... <br /> DEPARTMENT USE ONLY <br /> APPlleellen Aea"lof By O <br /> Dete � � IOM <br /> OreW Ineveellen By Deb Pomp In.Peetlen By <br /> not. <br /> De.bmOen ImnecSon By <br /> ACCOUNTING ONLY: AIDE <br /> FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKffm RECEIVED BY DATE <br /> PBIAITISEIIVICE REQUEST NUMBER INVOICE <br /> 2`tU of -2-1 0/40 � <br /> Pub.Health Sew,-Enviro.173(1/97) <br />