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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES L YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> AMMATION IB HERE BY MADE TO THE SAN"AWN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE VAR(OESCRIBEM TIIIB APPLICATION le MADE IN COMPLIANCE WITH SAN <br /> JOAWIN COUNTY DEVELOPMENT TNLE.CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JDAWIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMemN..L E� <br /> JOB AMMSBAR AM# A/P''y� 0 1-1 ---0 40 --3;Z CITY I PARCEL SIZFJAPHJ� <br /> OWNER'S NAME C7 r l"J O r^LL'lZ(N l7 ADOIa:eB A,IAh p P� O 1 1 QE <br /> BgN)NE I <br /> CONTRACTOR (�QdVN9 Z A RL-yslS, i/YLADpEeT f It'� RI� a0 UC.�✓4J INONEFo�O�1O00 <br /> e <br /> SUS CONTRACTOR ADDRESS me MORE( <br /> TYPE OF WELL/PUMP ❑ NEW WELL ❑ REPLACEMENT WEIL ❑ MONTMANIO vwuJ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT MPAM ❑ VAPOR EXTRACTION WELL, J <br /> ❑N—C3 R.W H.P. DEPTH PIMP SET_FT. FIRST WATER LEVEL O <br /> (IYFE OF PIMP( <br /> ❑ OVT-0E-SERVME WELL ❑ GEOPHYSICAL WELL♦ � BOIL BORING B <br /> ❑Of 6TRVCTION: <br /> MENDED USE TYPE OF WM CONSTRMI)ON SPECIFICATIONS A <br /> 11 INDUSTRIAL ❑OPEN BOTTOM VIA.Of WELL EXCAVATION VIA.OF CONDUCTOR CAMNG O <br /> ❑ OOMESTIC/I'PoVATE 11 GRAVEL PACK/MZE TYPE OF CAMHO/STEEL/PVC DIA.OF YMLL CASINO O <br /> ❑ "MRAUNMmAL ❑DRIVEN DEPTH Of GROUT SEAL SPECIFMATION q <br /> 11IRRIOATIVN/AG El OTHER GROUT SEAL H STAT I EO BY GROW BRAND NAME E <br /> ❑ MONITORING ! GROUT SEAL PIMPED: ❑Y. ❑Ne CONCRETE KVISTAL BY ORILLEH:❑Y. ❑Ne S <br /> APPROX.DEPTH IO LOCKNQ CHESTER BOX/STOVE ENP � p� �_2 S <br /> PROPOSED CONSTIIUCDONARIWNG NUMB! MUD ROTARY AIR RDTARY AUGER CABLE OTHERE�^T 'D &i c <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPICATION AND THAT THE YAY K WALL BE DONE M ACCORDANCE WITH BAN"AWIN COUNTY ORDINANCES,STATE LAWS.AND RULES ANO <br /> REGULATIONS OF THE SAN JOA WIN COUNTY. HOME OWNER OR LMENSEO AGENT'S SMNATURE CERTEES THE FOLLOWING:'1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WAIACN <br /> THIS PERMIT IB ISSUE TALL NOT EMPLOY RSONS"ACT TO RWAN'e COMPENSATION LAWS OF CALFOIMA.- CONTRACTOR'S HIRING OR MU ONTRACTM SRLNATUPE CERTIFIES <br /> THE FOLLOMM' • CERT TI <br /> THAT N E RMA E RK FOO WHICH THIS PERMIT IB ISSUED.1 SHALL EMPLOY MASON@ SUBJECT TO WORNAA I.6 CGMPDTeAMN"We Of <br /> CALNOPoJIA.- T APPUC MUST CA RIO <br /> rwd FOR On <br /> ALL REOURRD INSPfX:TDNe AT(EMI ISfieZS. COM/RETE DRAMNG AT LOWER AREA PHO FO. <br /> Slex� `"--) TIN. V, JJ-02,3//, C" �Wi <br /> ROT MN AN—Ie ee.l.)6e.,. <br /> A. NAMES OF STREETS OR MADS NEAREST TO OR 80I11,041,00 THE FROFERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR FVOMBED <br /> Z, MI LINE OF THE IIROPRTY.GIVING DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTEMS. <br /> 3. DffJFMIOMV OUTUNTS ANO LOCATION OF ALL EXISTNO AND PROMO O S. LOCATION OF WELLS WITMN MARKS OF ONE NUMBED FIFTY M <br /> STRUCTURES.NCLVVFNO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AIA WALKS. ON THE FPOPEnTY On AD"amna PAORERrY. <br /> De <br /> - Ill <br /> F <br /> TI <br /> — Ri AV c er. <br /> L;ams t.lc ; <br /> APPIIeHIm Ae Wtl BY l F V V EIMTMdT USE ONLY �/Z I L N. L�4 <br /> O.n <br /> Groin Irnnoelbn Bi D.. Rmv Imv.11en By G.1. <br /> Un.vrpllen Ignedbn BY D.I <br /> Cnmmwr <br /> ACCOUNTING ONLY: AID, FAC* <br /> PE CODES FEE Iwo AMOUNT REMITTED CHECKJMASH RECD EO BY DATE PEFMITIadVICE REQUEST NUMBER INVOICE <br /> Z Oi 89.0 LI/ C32.001Z <br /> z( 200 <br /> Pub Hea11h Saw.-Enviro.173("7) <br />