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SAPPLICATION FOR WELLIPUMP PERMIT <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERV <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 3K ,304 EAST WEBER AVENUE, STOCKTON, CA 55201388 <br /> (209) 468.3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CDmplets in TdplkBtal <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 81115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY//pU,BLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> 9 4 <br /> JOB ADDRESSOR AM# Q` I 'JJ CITY /iC,)�� Ad.n 4/^PAARC,EL 8S1JZE/AFN/ �G <br /> OWNER'S NAME {� (R S9 •_^1�(.,ADORE681I���S< KJ�I J'1��� ll• / ev RHONE ` '� �'�i <br /> CONTRACTOR ADDRESS. fy3 ' 1 (y , <br /> ��. I�J/�i- y� (�.�ln�l�//TJ•/J I�n71 <)�l'Y`i 1� •L1G, /L _PHONE <br /> BUB CONTRACTOR/V/JtU'CLL, J/iE/LG//V aL7U47/-L✓UMFJy ADORE <br /> PHONE <br /> TYPE OF WEUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL It ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP) <br /> 13Now 13 papal, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ❑ OUT-OF-SERVICE WELL 11GEOPHYSICAL WELL# may.SOIL BORING °' B <br /> ❑ <br /> DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I J� <br /> ❑ INDUSTRIAL 11 OPEN BOTTOM A <br /> DIA.OF WELL EXCAVATION 4t'�,�I/� - DIA.OF CONDUCTOR CASING <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/6TEELIPVC '0 V/C� DIA.OF WELL CASING <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROVE SEAL SPECIFICATION B <br /> ❑ IRRIGATION/AG ❑OTHER GROUT REAL INSTALLED BY- GROW BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PIMPED: Ely. ❑Na CONCRETE PEDESTAL BY DRILLER:❑Yw ❑Ne S <br /> APPROX.DEDTN LOCKING RESTER BOX/STOVE PPE /S <br /> CTINW <br /> WOMBED CONSTRUONIDNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER, <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPOISATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN HE PERFOR ANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUEOBHIA.' THE PPf IIT V )ALL 21 NO SIN ADVANCE F011 ALL REQUIR11iED INS 110NBrAaT 130pE1-MS �2]!. COMPLETE DRAWING AT LOWER AREA RgVI D. <br /> BIB/6/`K)rJTGIa / IJ7"Fe'-] �,CP�-C�(.�"6/Sl Dat. g r ' <br /> v 1\\ PLOT RAN (Draw b Scala)Sul. 'to <br /> 1. NAMES OF STREET$OR ROAD EAREff TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,DIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN MDIUB OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ... .:. '....... .. i-.._.. ... ........... .....i .: :.... ;. <br /> .. i.. .. ... . ..... <br /> .. .. 'i .. ... ... <br /> . ... .. <br /> i... ............ <br /> DEPARTMENT USE ONLY <br /> Application Aceeptad BY / 1 Data Y� <br /> Araa <br /> Great Impaction By Data Pmnp Inspection BY Data <br /> D.trwllon IRI ecti BY not. <br /> Comment.: N DfLMI qi;v, l M O <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NU,IBER INVOICE <br /> 1Dl q-5.5 G IMP <br />