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APPLICATION FOR PUBLIC <br /> HEA PER <br /> SA . AQUIN COUNTY PUBLIC HEALTH SE ES <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 /> (Complete In Triplicate) <br /> APPLICATION IB HERE BY MADE TO THE BAN MAGIAN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WTI(BAN <br /> JOAQUIN COUNTY DEVELOPMENT <br /> DEVELOPMENT TITLE.CHAPTER'9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SEVCED,ENVIRONMENTAL HEALTH D <br /> IVISION. <br /> JOB A017RE88/OR AM01040 •QCtYiEsh L1-g(c1, Ieet 'N, Stoc- toey PARCEL SIZE/AM# <br /> OWNER'S NAMEMS' Mgrttlw gowmojrlistet ADDRESS POO S1V, <br /> Pehrp GA 95663 p10NE/ 916 496-6416 <br /> CONTRACTOR PISC:4 �hV11''011N�2tjINQUp'py.�.,� AGGRESS 8 ace (IC13'39j AtW—ils F1 '] 9�Z92 26L 'x0.9 <br /> PHONE# Z17 7C-P!r <br /> RUB CONTRACTOR ADORES 741--411- S r t 1 h g L i C A NCE PHONE <br /> TYPE OF WELL/PUMP: 11 NEW WELL ❑ REPLACEMENT WELL ❑ MONnronmo WELL/ OTHER(7ecprClfd - OFFSj'� <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I a <br /> RVPE OF PUMP) 0N.13 Rep.1, N.P. DEPTH PUMP SET FT, FIRST WATER LEVEL 0 <br /> ❑ OUT-OF-SERVICE WELL ❑ OEORIYSICAL WELL# ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OFAYf{i C N I CONSTRUCTION SPECIFICATIONS ,Y Jp '{1 A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 4 iA DIA.OF CONDUCTOR CARING NIAA D <br /> ❑ DOMESTICTRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINOISTEM,TVC N ♦A DIA.OF WELL CASING N „ D <br /> ❑ PUBLICWUNICIPAL DRIVEN DEPTH OF GROUT SEAL N A SPECIFICATION R <br /> ❑ IRRIGATKINIAG ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME E <br /> MONITORINGC [[ GROUT SEAL PUMPED: ❑Yr ON. CONCRETE MOESTAL BY DRILLER:❑Yr ON. 5 <br /> APPROX.DFPTN 15 T t eT LOCKING CHESTER BOX/STOVE RPE S <br /> PROPOSED CONSTRUIOTION/DI9LUN0 METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER V F�QO PLD 611. <br /> 1 HERERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOADUIN COUNTY ORDINANCES',LTATE UWe.AND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COMRACTOn'S HIRING OR BUB CONTRACTING SIGNATURE CERTIFIES <br /> THE <br /> TIFY THAT IN <br /> E OF THE <br /> W FOR WHICH THIS PERMIT <br /> ISSUED,I SMALL EMPLOY PERSONS <br /> CAUFORNOWINO1:1E-�VPOCANT MUST CT1U.24 HOURS INADVANCEFOR ALL REQUIRED INSPECTIOH•SAT 1]091 A L"� 22.gCOMRFTE DRAWING ATTTO LOWER AREA AKINDFD�SA(nTO`N�Uwe OF <br /> 81'n X V Y c�..c•.PR— Tltls Pti•v j\c C M E1 h Q 9 6 D.t. I LZ i 9 r <br /> 1 <br /> MOT PLAN I Te Sew.)&.I. •Ie_ _ <br /> 1. NAMES OF STREEit OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF IIOUBE SEWAGE DISPOSAL SYSTEM On MiOPO6ED <br /> Z. OUTLINE OF THE PROPERTY,ORINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTEMB. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 9. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY Q A (�, <br /> APnlienlen AceeplM BY Dm rv� ` Ar.. l <br /> RroU Imveetlen BY Dna Pump ImP.mlen BY D.L. <br /> p,Mlrmllen Imexlbn BY COS <br /> p.,e <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INTO AMOUNT REMITTED CHECK#(CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 5 <br /> O ffloo <br /> Pub,Health Saw.-Enviro.173(1/97) <br />