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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIi; LINTY PUBLIC HEALTH SERVICES <br /> ENVIC%vIMENTAL HEALTH DIVISION <br /> 304 EAST WEBER"AVENUE,STOCKTON,CA 95202' <br /> (209)468-3420 <br /> RONAEFUMOABLE PERMIT E4F'H'3 1 PEAR FROM GATE 138IIEO <br /> ARLICATPON IB INRE BY MAOE TO THE SAN JOAC"N COUNTY FOR A PERMIT to CONSTRUCT to TopIL PNBTAIL'HE WOW DESCRIBED,710.APPLICATION Ig MAGE IN CO <br /> JOAOUIN COUP"DEVELOPMENT TITLE,CHAPTER 9-1115-3 AND THE STANDARDS OF CAN <br /> JDAOUIN COUNTY FURUC HEALTH OVIVICES,eNN1lOElIJENTAL HEALTH b1VIBpN. <br /> /f n 7� /+ MPUANCE WN118AN <br /> JOB ADbRE88/OA AFpNI/ (J-�jF-j/ T/(wJ 1` CIrY '-S_�, �j 2�, <br /> OWNER's NAME Me[ I�Ri[ I �l b [ ee (� lQPA/RCEL el FIAPNJ <br /> 1,1�/ 1!/L i� AbbRF.s J3� 77 T S ![3Fq f5.247 - <br /> COFTTRAcrOR � - PHONE B Z-3c�9 <br /> PUB CO „AvonEgg b2 371�6dPNONE, `fbZ'7G7�c <br /> HlRACTOR <br /> AOWIEBB W IlCI <br /> PHONE F <br /> JYPE OF WE{/PUMP ❑NEW WELL ❑REPLACEMENT WELL ❑MOFRTOT9Np WELL <br /> IF❑WRTALLAT'ON ❑WELL D"FEM REPAIR CITpS6 - ❑-I oiHER <br /> N.-❑Rep.l, ❑ COMNEtT REPAIR ❑VAPOR EXTRACTION WELL R <br /> HYPE OF MMPI H.P. DEPTH RUMP BET_FT. FIRST WATER LEVEt ..J . <br /> 13OVTaFSERVICE WELL 11GEOFHSam'. BYSICAL WELL I F . <br /> I <br /> RUCI ❑ BOR ' <br /> bE9TTIDN• J l 11 <br /> INTENDED UEE TYPE OF WE <br /> CONBTRVC HON SPECIEICATIOMs <br /> JI�INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION d <br /> /-DOMEettCSTtlVATE ❑OMVEI PACK/81ZF b1A-OF,CONOUCTOR CASINO O <br /> TYPE OF CABMOUBi ELE�yC_ OLA,OP;wrIL CASINO <br /> ❑RUSLIC"UNICR'AL ❑DIBVEH _(�n a�tiT O <br /> ❑IRHIGATPONIAO DEPTH OF GROUT 8EAL �� ATNIN - <br /> ©OTHER � SILdFIc A <br /> 1--, SROUt SEAL PISTALLED BY r�1^1 Je�y�' <br /> LJ MONR018H0 OIDVT DRANO NAME E _ <br /> I 1II <br /> GROUT gFA{PUMPED:�r <br /> APPROX.bCp TH /lL" I`'� ,h ❑Na N CO NCRETEPFnEsTALgYpWLLER:❑Yw ❑NO <br /> LOCKINO C 8 <br /> NESTER BOXlBTOVE PIPE- '+ <br /> PIW POSED CONeTRVCTIORR1WlIlTTO METHOD: MUD ROTARY AIR ROTARY ✓ .CABLE a <br /> AUGER OTHER <br /> 1 HERBY CERTIFY THAT I HAVE PI�PAAEO TlRg AF4LICATpN AND TNA 6 _ I4r <br /> T THE WOW WILL BE DONE IN ACC <br /> INANCE <br /> RELIULATION8 OFT"[BAN JOAOUIN COUNTY,HOME OWNER OR LICENSED AG ENT's SIGNATURE CERTIFIES THE O OWINO: I CETIFY THAT IN TTHN COUNTY EPERFORMANCE OFLTIIE WOISL FOR WHICH <br /> THIS <br /> PERMIT <br /> IS 1.9UE0,I.PIALI.NOT EMPLOY PERSONS SUBJECT TO WORKMAN'11 COMRWISATION LAWS OF CA,.ORNIA..CONTRACTOR'.WBONO OR BUBrCONTMCTU70$fONATURE tERTIPIE6 _ <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORL FOR WHICH THIS PERMIT is 188VE0,I SHALL EMPLOY 1'[RSONS SUBJECT TO WOROWFIAC CO MPWUTATUN LAWS OT <br /> CALIFORNIA.' 711E APPLICANT MVBT CA 71 110U1f IM ADVANCE F011 ALL REomorn 1:SPECT10NI AT 1"0147,111,COMPLETE DRAWING AT LOWER AREA PRONDEO, <br /> 9le.r.a A W r /// <br /> TIrt. a I <br /> PLOT FLAN opf T' <br /> 1,NAMES OP STREETS OR ROADS NEAREST TO OR BOUNOINO THE PPDI4RIYe" <br /> J, Ol1TlHR OF THF PnDpERTY,GIVING DIMENSIONS AND HORFH DIIIECTWN. ,41-LOCATION OF HOUSE SEWAGE OISI'O8A1 SYSTEM OR ILD79SEO 4 <br /> ].bPMENe1ONE0 OUTHNFe AND LOCATION OF ALL EXPRTRFO ANO PROPO8E0 �I EXPANSION F SEWAGE DISPOSAL BYBTEMS. <br /> STRUCTURES.INCLUOINO COVERED AREAS SUCH AS PATIOS ORIVEWAYB,AND WALRe O F <br /> S. <br /> LOCATION <br /> .E WELL.WTTISN RADIUS OF ONE NVNDAE <br /> ON THE ADPERTY OR ADJOINING PROPERTY. <br /> :... <br /> .. i....., __ <br /> S ..,.,. <br /> ..>_ _.. ..i......:. > <br /> `-. - <br /> I <br /> ... ... i. I. _ <br /> DEPAFIITMTNT Use ONLY /� d <br /> AFPSa.0-AveaPiwl <br /> Oreul k..Pmllen Br LO, <br /> Orl��nlbn LVR.ellen 0Y � I ':pH.1 Z?� v <br /> ' s sowd ttc.PY, f <br /> e1j t f J J G u1 T°11r' !f <br /> s <br /> ACCOUNTINe eMlYl ADF FACE ' <br /> PE COOEA FFE INTO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE FEFRATIBONICB RFOUEIT NUMBER INVOICE <br /> 31-5 <br /> Pub.HBaI[h Serv.•EnvIsG.173(1f97) - � � COPY <br />