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APPLICATION FOR WELL/PUMP PERMIT 0771 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Ijj <br /> ENVIRONMENTAL HEALTH DIVISION MAR 18 1999 <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 IVVfF l t`ilr (ojTpl HEALTH <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/ SERVICES <br /> (Complete In TTIpReEtE) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AMMR INSTALL THE WOR(DESCRIBED.Title APPLICATION 18 MADE IN COMPLIANCE WTIl SAN <br /> JOAOUIN COUNTY DEVELOPMENT TILE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> Lipo <br /> JOB <br /> JOB AODRE99rOR ARI/ vl �/� J /O/�yC—G ��U /L'rte CITY// //4T�TEct/Ay—/ �PPAMFI.S/MEIAPIM <br /> OWNER'S NA.&P? .S�(�e LtZS)r..E'.�112 PC.f—/I— � ADORES. {y��d p'l2/ /Rl/, / ) el PFIONEI <br /> / c <br /> COMMCTOR ��n' / /fir AE5UUCI PiIONE IJ2' <br /> SUB CONTRACTOR lxiV AODIi99 <br /> TYPE OF WELLMUMP. ❑ New WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑WELL smEM REPAIR ❑ CPOSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑HF.Y❑B.PW H,P. DEPTH PIMP SET—FT. FIRST WATER LEVEL O <br /> TYPE OF PUMP( <br /> ❑ OVE-0FSERVIOE WELL ❑ OEOPM'61CAL WELL I �'J BOIL BONITO B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS' L y r A <br /> ❑ INDUSTRIAL 11 OPEN BOTTOM UA.OF WELL EXCAVATION —J DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTICA'PIVATE GRAVEL PACKISRE TYPE OF CASINO/STEE11PVC � ���/ DIA.OF WELL CASINO /'LJ�/Jr O <br /> ❑ PIBLICMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL Q/CfcT/ 7 �"..�.. SPECIFICATION ~ R <br /> �❑{IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY JrEZ//--w� r GROUT BMFA NAME E <br /> p MONITORINGlcv�/1,B N1GLf�. \ GROUT SEAL RIMPEO: 11Y. 11N. CONCRETE PEOEETAL BY GRILLER:❑Yo, ONO S <br /> APPROX.DEPTH �� �" Q ba'p-I LOCKINO CHESTER BOXWOVE RPE ^ S <br /> PROPOSED CONSTRUCTONtORWNO METHOD: MUD RDTADY AIR ROTARY AMERp, <br /> .^ _CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WOR(MUL BE DONE W ACCORDANCE WITH SM JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND ACES AND <br /> MOLAATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNEn OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT m THE PER I MANCE OF THE WOR(FOR WHICH <br /> TISK PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S WRONG OR M"ORTMCTM SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- TIIE APPLICANT MUST CALL 2/HOURS IN ADVANCE FOR ALL REQUIRED INIRCT INS AT LKHR/'4111 <br /> _-24". COMPLETE O/MW1M AT LOWER AREA PNOVIDM. <br /> SIIneS X_ T10. OR. <br /> Of <br /> ROT PAN ID,—le Sa.l.l Sa.l. 'le <br /> l NAMES OF STAFF-A OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. I. LOCATION OF HOUSE SEWAGE DOIMSAL BYITEM OR PROPOSED <br /> 2. OUTLINE OF THE RIOPERTY,OIVMIO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 9. MMENIIONED OUTLMFS 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,DRVEWAYS,AND WALXI. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> :: Ste', ���� ,ate✓ Q�� c?:;r�o���'9 <br /> DEPARTMENT USE ONLY <br /> APPlle.11en AveePled BY D.1. % Y✓,� Ar.. <br /> Oreul Bvpeellen BY D.ta Pune In.pstlen By D.0 <br /> Dean�anen IrNn..lbn Br Da. <br /> cerrano-.0 <br /> ACCOUNTING ONLY: AID( FACT <br /> FE CODES FEE INFO AMOUNT REMITTED CHECK/X:ASH RECEIVED BY DATE P TISERVICE REQUEST NLMOM INVOICE <br /> 1 3 1-6 <br /> Pub Health Sen.•Emiro.173(1/97) <br />