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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION MAR 18 1999 <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 V�i' 1�1 v_ :f�IT al h 4i_I r! <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT % JE'-?V;CEG <br /> (Complete M TFIpRBBLB) <br /> APPLICAMN IS HEM BY MADE TO THE BAN JOAQUIN COUNTY FOR A FERMR TO CONSTRUCT ANVMR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE METH BAN <br /> JOAQUIN COUNTY DEVELOPMENT TELE.CH1APTER 81115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DMBION. <br /> JOB ADDRE99AR APHI �S',2 — 2/O—�G yfG e/ 1116 CIT � /'L''/��IDT�T�—z-f-�i1 PARCEL S?ZHAPNF <br /> OWNER'S NAMFJ ,�'/F/Y`•.�-SJ keeTX-Zp 'L.1iAZ ��^" �DOSESB J�I/�.c.�I�anV/���/" y'>" �r��1� RroHEI /Pq&l GAJ/C�^' <br /> CONTRACTOR Kt-/"y7.���F-C,�y��C ADDRESS S�«^!��'� UCI ` WONEI <br /> BUB CONTRACTOR SE'a�-/�CCL�/ ADDRESS Me 61?6a RroNElyc.r-��� <br /> TYPE OF W'ELLMUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONMORND WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CWSONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑Naw❑septi, H.P. DEPTH MMPSET_FT. FIRST WATER LEVEL O <br /> TYPE OF PUMP( <br /> ❑ OUT4)F-SERVICE WELL ❑ OEOMYSICAL WELL I AdVOIL BORING B <br /> ECI OESTRUCTroN ���o W� g <br /> /IN` / <br /> TENDED USE TYPE OF WELL CONSTRUCTION SPKIPCATIONS p r, A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION O DA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTICAPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINOISTEEL/PVC `` DIA.OF WELL CASINO O <br /> ❑ PUBLICMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL r(��1. / SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY �4'G�/�'�u'M GROW BRAND NAME E <br /> ❑ MONRORING GROUT DEAL MMPED;KY.. ❑N. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑N. 5 <br /> AI TIOX.DEPTH 3 (' LOCKING CHESTER BOXISTOVE RPE B <br /> PROPOSED CONSFRLIOTONDSLUM METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HMBY CERTIFY THAT I RAVE PREPARED THIS APPUCAMN AND THAT THE WORIL WILL BE DONE N ACCORDANCE WITH SAN JOA WIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> MOULATION9 OF THE DAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT N THE FERMANIANCE OF THE WORK FOR WHICH <br /> THIS PEANUT IB ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMIDISATION LAWS OF CALNORISA.' CONTRACTOR'S HINNO OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMFLQY PERSONS SUBJECT TO WD M'S COMMNBATION LAWS OF <br /> CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED HIRMTKINS AT VINSI11811414". COMPLETE DRAWING AT LOWER AREA FROVIDD. <br /> SIB.Hd X TIN. ! <br /> /LOT PLAN ID,.v,1.D.ti.l D..I. '1. <br /> 1. NAME STREET. OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DEPOSAL SYSTEM OR FROMSED <br /> i. OUTLINE OF THE PLIOMM.GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> G. DIMENSIONED OUTUF F.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN MONS OF ONE HUNDRED FIFTY FT. <br /> STRRICTUMS,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY <br /> ♦OR ADJONIM PRORRTY. <br /> ..:. .. < ... ......5... .�. .: .. .�.... <br /> I' DEPARTMENT UBE ONLY <br /> AIIIb611en A... W BY <br /> G..M Imve.11.n <br /> By _IA/\ D.,. __F—P I-p—lon By SIR. <br /> Dmu,cB.n Imn.mlen Br D.I. <br /> c.mmer.. <br /> ACCOUNTING ONLY: AID/ FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXIICASH RECEIVED BY DATE PEIIMITRERVICE REQUEST NUMBER INVOICE <br /> 6— 2l ! PE <br /> Puh 4aAKh Sarv.-Enviro.173(1/971 <br />