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APPLICATION FOR WELLIPUMP PERMIT <br /> "• V JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �* ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r <br /> I <br /> APIICATIn"IS HERE BY MADE TO THE SAN JOAITUIN COUNTY FOR A PERMIT TO CONSTRUCT AFNO/OnI INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOADMN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. <br /> JOS ADORESSIDR APNI 1'L' �(�Lll y t L f / L �S�Zee-3`y <br /> P-1 <br /> ` ,R G f t Ll CITY C c l7 A't_ PARCEL SIZE/APNI ZS�—Z Orr— 7 <br /> OWIIFn'R NA ME (W1 G.IIS �A✓�yP ';J 7,�,.I,K AODREBS <br /> .� . SPHONEly <br /> � l3�6-314 0 <br /> CONTRACTORESS C <br /> UCF PHONE <br /> SVR CONTRACTOR (J'-✓`C c�ay 1 I I 1✓1'� ADDRESS 47! tt l Rr4 UC► S—.-, <br /> TYPE OF WELL/PUMP: ANEW WELL ❑REPLACEMENT WELL MONITORING WELL I E4 W — ❑OTHER <br /> ,ay ❑INSTALLATION ❑WELL SYSTEM nEPAiR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL/ <br /> H VIDE OF PUMP � <br /> ON—Elp—rR H.P. DEPTH PIMP SETFT• FIRST WATER LEVEL p <br /> ❑OUT-OF-SERVICE WFLL ❑DEOPIYSICAI-WELL/ ❑ SOK BORING S <br /> ❑DEe-InUCTION: <br /> `r INIENOED!LSE TYNE OF WELL CONSTRUCTION fPECIFICATIONt I1 ^ <br /> ❑INIxISTRAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONOMT09 CARING <br /> p <br /> 11 DOME 11CIPRIVATE ❑GRAVEL PACKMIZE TYPE OF CARINSRITEEL/PVC 7 I I // L GIA.OF WELL CARING 1 p <br /> ❑PURUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R - <br /> `� 0 IRRIOATIONIAO OTHER GROUT SEAL METALLED BV X GROUT BRAND NAME E <br /> IIs'MORRTOnING / — GROAT REAL PUMPED:❑Ye• N. CONCRETE PEDESTAL BY DRILLER:Ely- [IN.e 5 .. <br /> APPROX.01""70 W LOCKING CHESTER BOXIRTOVE PIPE a <br /> PROPOSED CONSTRUCTION/DRILLING METHOD:MUD ROTARY AIR ROTARY AUGERV-- CABLE OTHER <br /> I HE"'NY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TIIE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> PFOULATIONR OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AOEM'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TIIE WORK FOR WHICH <br /> THIS PRMIT in IRSUFO,1 SHALL NOT EMPLOY PERSONS RURJECT TO WORKMAN'*COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRINO OR RU"ONTRACTING SIGNATURE CERTIFIER <br /> TIIE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK TOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF <br /> CALEORMA.' T APPUEART VET CALL ZI NOUM*1 ANCE FOR -.I.. <br /> IM*►(ETIONt IZOfI ft_ftlS.COMPLETE 11—AT LWE <br /> OR AREA PROVIDED. <br /> e�YPP-d x c l(-•'E^^ nn.f N.;7 I� i9�P c 4 r/ <br /> PLNPlr <br /> noOt PUN to..w Ie Seri Rer•_ / ••le_� <br /> 1.HAMFR OF RTRFETS OR ROADS NEAREST TO OR B F W.-THE PROPERTY. T 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On MKIPOSEO <br /> ].OUTLINE OF THE PROPERTY.OIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF REWAGE DISPOSAL SYSTEMS. <br /> �.DIMFNRIONED OUtLIHFS AND LOCATION OF ALL EXISTING AND PROPOSED f.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE P OPERrY OR ADJOINING PROPERTY. <br /> .. ' <br /> To . <br /> P'°PL,S`a 1 /-101.1,Fir 1.11 71 <br /> mo-3 Mw%-3 ♦ s <br /> 0 <br /> KO-4 <br /> f /�lrl✓/ <br /> DEPARTMENT USE ONLY <br /> r APPRe•Ibn A—I d Ry Dale A— <br /> OIM 1PNPeellen Rr One Pump FI•P••Sen Br De1e <br /> Dwbmllen Mvrlbn Br D•b <br /> Cernm•rN.: <br /> PSI <br /> ACCOUNTWO ONLY: AID/ FAC/ <br /> ►E COOEf FEE INFO AMOUNT REMITTED CHECKPMA*N RECEIVED BY DATE PORRA TISERVICE REGUEff NUMBER INVOICE <br /> �r <br /> Pub.Health Serv.-Enviro.173(1/97) <br />