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APPLICATION FOR WELIC HEA PERMIT <br /> ' SAN�pUIN COUNTY'PUBLIC HEALTH SES <br /> NVIRONMENTAL HEALTH DIVISION* / I2 <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> BBN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED ORIGINAL <br /> IComplels in TrIprNM1#1 <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR PERMIT TO CONSTRUCT ANDMS INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> JOAGUIN COUNTY DEVELOPMEEN/T TRI/F�CHAPTER B-1/1 j15.3 AND THE STANOAROB OF SAN JOAQUIN COUN/�TY PU/BU/C HEALTH SERVICES,ENVIRONMENTAL HEALTH nMs10N. <br /> JOB ADORESS/OR APN#y// Ip FC/N(/OI N ( P N�E 1�- Citt S]0 C/t]T/N "'S.�8.w�T <br /> PARCEL SIZUARJI <br /> �B li.v9 Dr.y be ,v��a,-n 7[s (SD Ds) /900 Trowell 'n F...IL.d P-. <br /> OWNER'S NAME �O TL- IcC T L3 CLp(C ADDRESS � � <br /> Ernarh r=l �/ C,q 9Y60N "/PW'2 PHONER <br /> CONTRACTOR <br /> AODRE88 LIC# <br /> PHONE I <br /> SUN COMRACTO"' pe �r-u„-. ADDRESS tec>'�.+9 A Sao UC#CS7-S/�368 <br /> PHONE <br /> TYPE OF WELL/PUMP: ® NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> A� J <br /> /✓ ❑New❑ibpdr N.P. pETH PUMP GET A//H FT. FIRST WATER LEVEL O <br /> DYPE OF P1MPI "'777""" <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ COIL BORING B <br /> El DESTRUCTION: <br /> INTENbEO USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 11 INDUSTRIAL ❑OPEN BOTTOMA <br /> GIA.OF WELL EXCAVATION � p DIA.OF CONDUCTOR CASINO /{�/A <br /> 11DOMESTICA`FUVATE ®GRAVEL PACK/91ZE # ��O TYPEOFCASINW6TEMYPVC SCrf/ NO P'l'C DIA.OF WELL CASINGD <br /> _ <br /> ❑ PUSLIC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL ..30/ SPECIFICATION 1 <br /> APPROX. L O <br /> ❑ W11RO <br /> RIGATION/AO OTHER GUT BEAL INSTALLED BY �Y/��e r GROUT BRAND NAME <br /> AP /}/P0.L Qe y}I eNG E <br /> O G /J GROUT SEAL PIMPED: ® ❑Ys No CONCRETE PEDESTAL BY DRILLER® ❑Ys Nc S <br /> DDq DEPTH Y O' LOCKING CHESTER BOXISTOW RIFE UPS <br /> PROPOSED CONSTRVCRONRHNLUNO METHOD: MUD VOTARY AIR ROTARY AUGER_/ CABLE OTHER <br /> 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPJCATION AND THAT THE WORK WRL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IB I69UED,1814ALL NOT EMPLOY PERBON8 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS HIRING OR SU"ONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CETIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPOISATION LAWS OF <br /> CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOU REDINS//PECTIONS AT(2001 403J422. COMPETE DRAMNO AT LOWER ARA PPpVIDED. <br /> B'I"x �-:�� O �.'c-e THRs Oo <br /> c PI-0– y— Do. <br /> POT PLAN nw..I.B W.l&.1. 'to <br /> 1. NAMES OF BTRFTB OR ROADS NEAREST TO OR BOVNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR RW POSED <br /> 2. OUTLINE OF THE PDOPRTY,GIVING DIMENSIONS AND MOTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> O. DIMENSIONED OUTUNFG AND LOCATION OF ALL EXISTING AND PROPVSM S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY T. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAMS. ON THE PROPERTY OR ADJOINING FROPERTy. <br /> MApfta <br /> DEPARTMENT UBE ONLY <br /> APPIIe.IInn Accepted BY <br /> Dm [ V <br /> Greut IMO«Ren Bv_ Dns P,,,.,.L,.._..a-..By <br /> D-111 0.n InP«Ila By <br /> ee,nine,e.: Z69 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO MOUNT"EMITTED CHECK#/CASH PECOVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> Pub.Health SEN.-Enviro.173(1/97) <br />