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PLICATION FOR WELUPUMP PER <br /> MI <br /> SA*AQUIN COUNTY PUBLIC HEALTH SEES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 NOv <br /> (209) 468-3420 JQA S��GE <br /> QVI <br /> NOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM MITE ISSUED SAN "iz (V1S101+ <br /> P116lMFN'fAl FA- <br /> (Complete in TFippeeul ENVIFON <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WON(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSMA APN# 5' SI PRF) F J C .4 Ve VL/C Clry S'TC'G-iC r9/� PARCELBREIAPN/ AVY'140-C%I <br /> OWNER'S NAME/ Af/r-9 4-j"CGC ADDRESS T;1-yE fygs Jed RHONE ZfjV -s-Z <br /> CONTRACTOR L�-1�/Qx L-'✓_'lC eWe- ADDRESS Z��zy.� L ' 'e 1)C�7I.��41 PHONEI �L)�/ "116.e"Ji <br /> RUB CONTRACTOR ADDRESS {•�N me PHONE 0 7` <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL e J <br /> ❑N.11 Rep.ir N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> (TYPE OF PUMPI r <br /> ❑ OMOF-SERVICE WELL ❑ GEOPHYSICAL WELL I ..WSOIL BORING <br /> ❑DESTRUCTION: 777 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING 0 <br /> ❑ DOME9TICTRIVATE EI GRAVEL PACK/SIZE TYPE OF CASINOISTEEL/PVC DIA.OF WELL CASINO D <br /> ❑ PUBLIC MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> '�rPE{\'njL�IRRIAATIONIAG 13 OTHER GROUT SEAL INSTALLED BY BMW BRAND NAME E <br /> 1J MONITORING OROUTSEALPIMPED: ❑Y. [IN. CONCRETE PEDESTAL BYOMMER:❑Y. [IN. S <br /> APPROX.DEPTH LOCKING CHESTER SOXMOVE RPE <br /> 5 <br /> PROPOSED CONSTRUCTIONIdOLUNG MEFHOO: MUD ROTARY_ AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN 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:'I CERTIFY THAT IN THE PERFORMANCE OF TINE WOW FOR WHICH <br /> THIS PERMIT IB ISSUED.1914ALL NOT EMPLOY PERSONS 8 EJECT TO WORKMAN 4 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRNO OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMAI E OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE APPUCANT MUST CALL 3/ROUES 1 ADrVANCE OR ALL REQUIRED INSPECTIONS AT 130914004M23. COMPLETE DRAWING AT LOWER AREA PION <br /> 811r x ✓ TRI. i.DENT D.I. <br /> ROT dAN ID,µle Se.bl%.1. 'Ie <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL BYBTEM On PROPOSED <br /> 3. OUTLINE OF T14E PROPERTY,GIVING DIMENSIONS AND NORTH DInECTION. EXPANSION OF SEWAGE DIBPOBAL 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,DRVEWAY8,AND WAUK8. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> t Itc) <br /> �h T ENr USE ONLY 1 I L <br /> np.nenep <br /> len Aeeled eY 1�LIAV�!)AY/`rlLl\ D.l� Ar. <br /> GrpU In.p.11en By <br /> Dae PumPlmpmOan BY DHe <br /> D.I. <br /> Drranretlen ImP.eRbn BY <br /> Cemmenb: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODESgz� <br /> AMOUNT REMITTED CHECK CASH RECEIVED BY DATE POWITISERVICE REQUEST NUMBER INVOICE <br /> 3 5 S P 3 537 15 I I 00 %Z y <br /> 3S3g 3 <br /> Pub.Health SEN.-Enviro.173(1/97) o <br />