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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN&OUIN COUNTY PUBLIC HEALTH SEOES <br /> ENVIRONMENTAL HEALTH DIVISION % `S <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 466-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED n ' <br /> (CBmPMti In TIIpOCELeI <br /> APPLICATION 1914E BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AUTHOR INSTALL THE WOR(DESCRIBED.THIS APPLICAT I M 150111'U A N <br /> JOAQUIN COUNTY DEVELOPMENT TSN/U..CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY,IPUUBLIC IIEALTN BEIM ES.ENVIRONMENTAL HEALTH DIVISION.JOR ADORESSMR A'(P�NI 235(o I !S- Sah� Fey Cm �4" PARCEL SIZEIAPNI <br /> OWNER'S NAME /JDLL I`hI�.�- k I ��1/'p` ADDRESS �pI /J RIONEI -E <br /> CONTRACTOR farrow FLi��` c"E,JV Js ADDRESS IJn��JI L th41Alih5 Ucs C PHONE.57q 00 <br /> SIBCOMMCTOfl11��! ADDRESS L�J�SL�E✓t�•fl'LJ(/'e`�1 UCI JI LZ.. (I PIONEI��Z <br /> TYPE OF WfUJPIIMP• lE NEW WELL(4) ❑ REPLACEMENT WELL El MONITORING WELL I ❑ OTHFR <br /> INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CCVSi ONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ✓ <br /> ❑ <br /> N.❑Rr.M IT P— DEPTH PUMP SET—FT. FIRST WATER LEVEL 0 <br /> NUPE OF MMPI <br /> ❑ OUT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL I SOIL BONITO 0 <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE—OFWEU CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION (SLI CIA.OF CONOVCTORCASING /VT O <br /> ❑ WMESTICPRIVATE RORAVELPACK/BRE M-r TYPE OF CASINGISTEEL/PVC F'VOIA.OF WELL CASINO ZII 0 <br /> ❑ PUBLUCWUNWWAL ❑DRIVEN DEPTH OF GROW SEALZD ( L_ SPECIFICATION 0 R <br /> �❑ IRRIBATIONIAO ❑OTHER GROUT SEAL INSTALLED BV i O t.�TLwn GROUT"MND NAME ( E <br /> �l MONITORING I OROUT SEAL PUMRO: .' Yr ❑N. CONCRETE PEDESTAL BY DRILLER: Y. ❑Ne S <br /> APPROX.DEPTH dO LOCKING CHESTER BOX/STOVE S <br /> PROPOSED CONETRIICTH)N/ONLUNO METNOO: MUD ROTARY AIR ROTARY RIMER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH BAN JOACHIM COUNTY ORCINAMEB.STATE LAWS.AND RULE"AND <br /> "EDR <br /> GULA F THE BAN JOACURN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWNHO'I CENTNY THAT IN THE PEPTORRAANCE OF THE WORK FOR WHICH <br /> T PMR IB 1 VE0.1 S1ULL NOT EMPLOY PERSON"SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALRORMA.- CONYMCTOR'B MHO OR BUBLONTRACTNIG <br /> O SIGNATURE CERTIFIES <br /> 74 FOLLOVAN u I CERTIFY THAT N T11E R RMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WNIIWAN'S COMPENSATION LAWS OF <br /> CA RMA.- T APPLICANT MU A IN ADVANCE FOR ALL REQUIRED INS�yR'�C'FONG AT I209I 4"i ". COMPLETE DRAWING AT LOWER AREA PIOVID O. v <br /> Till / //LN � • <br /> B1mai X V <br /> PLOT MN ID,.to S W-1 eatl. 'to <br /> 1. NAMES OF STREETS OR ROAD ARREST TO OR BOUNCING THE PROf4RfY. A. LOCATION OF HOUSE SEWAGE DIRMITAL BYSTEM OR PROPOSED <br /> 2. OUTUM OF THE PIKIPERTY, DIMENSIONS AND NORTH DIRECTION, EXPANSION OF BEWADE dBPOSAI SYSTEMS. <br /> 9. DIMENSIONED OUTLINES ANO LOCATION OF ALL EXISTRIO ANO PROPOSED S. LOCATION OF WELLS WRITER RADIUS OF ONE HUNDRED fnlY ET. <br /> STRICTURES.INCLVNND COVERED AIDS SUCH AS PATIOS.DRVEWAY8.ANO WALBS. ON THE PROPERTY OR AOJONNG PIgPERTY. <br /> DEPARTMENT USE ONLY <br /> APPII..tlat A.e. Im BY <br /> Orvul kepeCtbn By O.ts Rime Imvxllen By D.t. <br /> U+Inctlen Ir.Rrtbn B <br /> ACCOUNTING ONLY: AID/ FACS <br /> PE CODES FEE INTO AMOUNT REMITTED CHECKIMASH RECEIVED BY DATE PF TUSERVICE REQUEST NUMBER INVOICE <br /> 3 - ! <br /> Pub Health Sew.-Enviro.173(1/97) <br />