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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WIEBM AVENUE,STOCKTON.CA 95201388 <br /> (209)458•3320 <br /> NWREFUNDAPLE PERMIT tMKS 1 YEAR FRDY DSTE ISE0E0 <br /> tCDepl{bA in TrtpButa) <br /> APPLICATION W HERE BY MADE TO THE SAN JOACI M COUNTY FOR A PEVAIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THF STANDARDS OF SAN JOAOUN COUNTY PUBLIC HEALTH SERVICE'S,ENVIRONMENTAL HEALTH DPiKB10N. <br /> JOB AODREBMR APT# )a L,SD LA)• p)eTLT I 1p Vl CRY Tp ae- PARCEL SMAPH/ �'�j' <br /> OWNER'S NAME Lo LA <br /> w;e C{pI I1 Iag1EC{ AQL -e- Nn,, PYAf1E J/F.JJ—Q!4:1 <br /> GONTRACT011. �!^j'-�4 t L-� )GC r r �rI C.• ADORERS�4�GX�L� K.j?• L1CI�539�Z PNONE, � <br /> SUS COMRACTOA ADDRESS LICJ PRONE J <br /> TYPE Of WELLRIIMP: ❑NP'v WELL ❑REPLACEMENT WELL ❑ MONITORING WELL f ❑OTHER­ <br /> t4 INSTALLATION ❑WELL SYSTERA REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTAACRION WEu B J <br /> _S G LSFJ.w❑t4o.b H.P. DEPTH PUMP BET----FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑OUT-0f-BflLVICE WELL ❑OEOPHYSCAL DEL./ ❑ SOIL'AOMNO : B <br /> ❑DESTRUCTION: <br /> afetwim USE rs SpeclRdATION4 A <br /> ❑I- INUSTRIAL 1]OPEN BOTTOM DW OF WELL EXCAVATION CAA.OF CONDUCTOR CARNO D <br /> G<MESTCRWVATE ❑GRAVEL PACKISZV� TYPE Of CA6N4a75TEELfi VC DIA.OF WELL CASINO D <br /> ❑PNBLJClI.RRaCIPAL ❑DRIVEN DEPTH OF GROUT SEAL _ SPECDiCATION <br /> ❑PRIOATCWAG ❑OTHER GROUT SEX INSTALLED SY _ GROUT BRAND NAME tl�•�• <br /> ❑MONITORNG OAOUT SEAL PUMPED.❑Y- ❑N. CoNCRET£PEDESTAL BY DwurE❑Ym ❑N. S6 <br /> ANRLOX.DEPTH LOCKING CHESTER BOXIWTOVE PIPE_ O <br /> PROPOSED CON{TRUCTIOkIDPRUNO METHOD'MUD ROTARY AIR FIOTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOF%WILL BE DONE IN ACCORDMNC2 MTN SMI JOAOUM COUNTY ORDINANCES.STATE LAWS.AND RULE{ <br /> REGULN <br /> ATIONS OF THE SAN JOAOUCOUNTY. HOME OWNER OR UC{NWD AGENT'S WGINATURE CERMK <br /> CERTIFIES THE FOLLOWING:T CERTIFY THAT IN THE PERFOAME OF THE WORK FOR WHICH <br /> THS PERMIT IS MSUEO,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPBOATION LAWS OF CAIJFOMIA,'CONTRACTOR'S HANG OR SUBCONTTNCT}NO SIGNATURE el" <br /> THE FOLLOWING: 'I CERTIFY THAT N THE PERFORMANCE OF THE WOWI FOR WHICH THIS FEMAR IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WOMDAAN'{CO"mx*ATION LAWS <br /> CALPOr1AlUL' T AMT MVR ALL N NOLAIN N ADVANCE FOR A:L RFa1Mm INST AT UNYN){M34if COMPLETE DRAWING AT LOWER AREA PIIDV10E0. Q <br /> ROT RAN 10" 1.Buy 6wA <br /> 1.NAMES OF STREETS OR ROADS NEARER TO OR SOUNDNO THE PROPERTY. !. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 7. OUTUNE OF THE PROPERTY,OIVSIO DIMENSIONS AND NORTH OIRRECTION. EXPAMSIOFI OF SEWAGE DISPOSAL SYSTEMS. <br /> 9.DIMENSIONED OUTLNAND fe ALOCATION OF ALL EXISRNO AND PROPOSED S.LOCATION OF WELLS WTTHH RAMS OF ONE MP40MD FWrY FT. <br /> STRUCTURES.NCLUOINO COVERED AREA"SUCH AS PATIOS,ONVNNAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PFROPE1EfY- <br /> `\ .. ! .. <br /> i <br /> .... ....:... .. ..i... .>,... .... <br /> • i <br /> If <br /> J. <br /> i <br /> • <br /> c• <br /> : <br /> �4 <br /> ... ...`. <br /> : . .;.. .>.....:....i.... .. <br /> .. .'.....:... .[. .:7.......i.. .. .... <br /> ...... ...... <br /> ... <br /> ..i...'.... . ......... ..t . . . . _ .:.. <br /> : .. ;. ..`.................. N V <br /> t 7AwEt�LT.H l7iV1G� <br /> NSPARTMENT USE ONLY <br /> Appilatl.n Aoa+Im 8y � DO. <br /> 6r.u1 h.pmlla,8Y, tmm Puny IroP 0-BY E <br /> Denrualwn Nr.p.otlon BY OMe <br /> ACCOONTINO ONLY: A. FACT -74O <br /> m coo" FEE INFO AMOUNT POWT TIM !CASH R clilvm■Y DATE POMTISBWCE RLGVE{T AILA" <br /> ( �^ 03 q-,=b <br />