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APPLICATION <br /> FORWEL�PUMP PERW g� rSAQUIN UNTY PUBLIC HEALTH ES; T � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 JUN 04 <br /> (209)468-3420 <br /> MON.REFUNDABLE PERMIT EXPIRES I YEAR FROM OAT E ISSUER <br /> VT <br /> Memplets In'Fripkatel PER j Q. T� <br /> APPLICATION 18 ITEM By MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAN <br /> JOAaUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. <br /> JOB Anf)RIE&'%/OR APNO P-,-",Ad PARCEL 8tZE/APNv'2?s-0,?o --0 <br /> OWNER'S NAME -rwc) ADDRESS PHONE, sA2&t-5cp <br /> CONTRACTOR_41k!�W ADDRESS NMNIMD�Q.ucs-!Ye�QPHONE* 1r&7 /dD6 <br /> SUE CONTRACTOR —ADDRESS LICE PHONE# <br /> TYPE OF WELLIPUMP: E1NEWWELL ❑ REPLACEMENT WELL ❑ MONITORING WELL IF 1-1 OTHER <br /> ❑ wrAuLATION El WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR (3 VAPOR EXTRACTION WELL# i <br /> ❑New L-1 Repair H.P. DEPTH PUMP SET FT. FIRST.WATER LEVEL 0 <br /> (TYPE OF PUMPI 0 OUT-OF-SERVICE WELL El OFOPRYWAL WELL$ 6�ZL BOMWI <br /> L1 DESTRUCTION; <br /> IN FENDED USE TYPE OF WELLL CONStMiON SplICIFIcATI—ONE A <br /> 11 INDUSTRIAL 11 opm Borrom DIA.OF WELL EXCAVATION l DIA.OF CONDUCTOR CASING <br /> 0 DOMESTICIPRiVATE ❑GRAVEL PArKMIZE TYPE OF CASINWOTEELIPVr DIA.OF WELL CASING <br /> 11 PUBLICAMUNICIPALo VIEN Qftw&6e., DEPT"OF GROUT SEAL SPECIFICATION <br /> 11 IIO4 <br /> GATNrAQ W, q <br /> HER GROUT ISEAL INSTALLED BY C4'Z- CAROUT BRAND NAME <br /> �r <br /> MONITORING GFV04JT SEAL PUMPED- Ll Yea [IN. CONCRETE PEDESTAL OYOFULLEFI:[Iy. [IN. s <br /> APPROX.Dt"m f15 LOCKING CHESTER 13OXISTOVE PIPF-- <br /> PROPOGED CONSTRUCTIONIMLLING METHOD: MUD ROTARY_AIR ROTARY- —AUGER--CARLEOTHE <br /> — <br /> 1 HEEWSY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AVIO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOA(MM COUNTY ORDINANCES.STATE LAWS,AND RULES AN; <br /> REGULATIONS Of THE MAN JOACUIN COUNTY. H0kW OWNER OR UCtNEED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT is ISSUED,I @"ALL NoT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA-- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> 714E FOI-kOWI"Q-- 'I CERTIFY THAT IN THE PERFORMANCE OF THE%,%-ORK FOR WHICH THIS PERMIT 19 ISSUED,I SHAU EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' T "T MUST Pules IN ADVANCE FOR ALL REOMR60 IN94MMS At 12011)460 M23. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 7q1910nod x )Wauy-';� Date <br /> PLOTPLAN fD,ow to Gavle)Ikel.— to <br /> 1. NAMES Of @TRM6 OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4, LOCATION Or"OUSE SEWAGE DISPOSAL SYSTEM on pRopagiro <br /> 2. OUTLINE OF THE PROPERTY,OWM DIMENSIONS AND NORTH DIRECTION. EXPANSION 01:SEWAGE DISPOSAL SYSTEMS. <br /> 3. bIMMSIONFD OUTLINES AND LOCATION OF ALL EXISTING AND PFIOP09ED S. LOCATION OF WELLS W"MN RADIUS OF ONE HUNDRED FIFTY Ft. <br /> STRUCTUFUES,INCLUDING COVERED AREAS OUCH AS PATIOS,DRIVEWAYS.AND IrVALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> nth too <br /> p <br /> ........... <br /> m <br /> m <br /> m <br /> ................... ........ <br /> ApplicalIon Accepted -6t r",-yt� DEPARTMENT USE ONLY aeOMv -fi'f/Lt 7S '00m— <br /> Grout kopwqten BY <br /> 17 Dere wqPomp Ingpeaftm BY bate- <br /> ansi.q.tion I—pection It ONe <br /> rl <br /> ACCOUNTING ONLY; AJOI FAC/ <br /> RECEIVED DATE rum <br /> PE Cc"@ FEE INFO AMO REMITTED CHECKWMARH- - .1 TfSTRV10E RIFOUEST NUMBER INVOICE <br /> aa/6-9 <br /> Pub,Health Serv.-Enviro. 173(1197) <br />