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APPLICATION FOR WELLIPUMP PERMIT <br /> SAtoAOUIN CO+iNTY.,',UBLIC HEALTH SEES Wi <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209' 4.342° O R I GI N <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ;w <br /> IComplt(t in Triplicate) <br /> APPLICATION IS HEM BY MADE TO THE SAN JOAQUIN COUNTY FOR PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK MSCNBED.TRM APPLICATION I6 MADE IN COMPLIANCE WTII SAN <br /> JOAQUIN COUNTY DEVELOPMENT TRLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLILIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION <br /> / 1 .J/. sT/ac..E 101-, 'J3,N•l f- <br /> JOB AODRE6SIORAPNI 376 /CY YveO� IU/ r' CITY PARCELSIZUAMN GYI S R/p-(UpOAL <br /> S /"3 D r j Cka e,!5 e ef' A+e laZ taCD.r /9A7 aurt/ t�.<Y, i.T r. <br /> OWNER'S NAMEe�AI 1dT [3 Od JSa� ,(eu' GF 'eE RetARJ ADDRESS"' r� UZ'//rl�lJ 9yLOP-/YJ7 IvwNEFso-Gs2.VS <br /> CONTRACTOR ADDRESS LICE PHONE/ <br /> ((77 �I A ,( 6s lJ�,ua�l Dr <br /> PH <br /> SUBCONTRACTOR Nl/?�o0 Pr IIvv ADDRESS . M .Ff� Cl fl 9SJOS mE/'-S'7 �.76DONE t,�09-5'6S-P7i <br /> TYPE OF WELL/PUMP: W NEW WELL ❑ REPLACEMENT WELL IGI MONITORING WELL E ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CMSS.CONNECT REPAIR ❑ VAPOR EETRACTTON WELL E J <br /> /V/A ❑New❑n".I, N.P. DEPTH NMP SET.AAET. FIRST WATER LEVEL O <br /> (TYPE OF MMPI <br /> ❑ OUT-0E-BERNCE WELL ❑ OEORIV61CAl WELL A ❑ SOIL BONITO B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WF1L CONbTRUC TION SPECIFICATIONS n A <br /> ❑ INDUSTRIAL ,L❑,DIOPENSOTTOM DIA,OF WELL EXCAVATION /0 DIA.OF CONDUCTOR CASINO AI/R O <br /> ❑ DOMESTIC5'DIVATE WIORAVEL PACKISIZE# 6 TYPE OF CASINO/6TEELRVC-: / yO /'`P- DIA.OF WELL CASINO �e� O <br /> ❑ MBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL TTSO y SPECIFICATION 1 .A. R <br /> ❑ IRRIGATMNIAG ❑OTHER GROUT SEAL INSTALLED BY NJ r%Ile r- GROW BRAND NAME Aea L elIectq m eNL E <br /> ® MONITORING o OPOUT SEAL PUMPED: ®Ys ❑Ne CONCRETE PEDESTAL BY DNLLER:IDI Y— [IN. S <br /> APPROX.DEPTry O O LOCKING CHESTER BOX/STOVE%PE pos S <br /> WOMBED CONSTRUCTIONMIULUNO METHOD: MUD POTARY AIR ROTARY AUGER_CABLE OTHER <br /> I HEREBY CERTIFY TIIAT I HAW PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REOULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PLWORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IR ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFOMA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN TILE PERMAMAME OF THE WORK FOR WHICH THIS PEIMT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12V•I 4Mb 22, COMPLETE DRAWING AT LOWER AREA IRIOVIDEO. <br /> a UI. c 7� , <br /> Blab x <br /> roi p <br /> PLOT PLAN ID,-1.Se.lel lk.l. 'to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PBUMSED <br /> P. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. _ <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND MOMSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTUMB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRVEWAY6,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY <br /> APPIIWIS .AeeeplPJ BY <br /> Grew TMPeclleo BY Da. _ PvnP Imv.mlan BY O.b <br /> Dm,nctlen In.nxtlon By D.I. <br /> ACCOUNTING ONLY: NDE FACT <br /> PE CODES FEE INFO AMOUNT IMNUTTED CRECK//CAS" RECOVED BY DATE P9MITISERVICE REQUEST NUMBER INVOICE <br /> '5'55q3 C s 20 D((P3 <br /> Pub,Health SeN -Enviro.173(1/97) <br /> So, <br />