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APPLICATION#FOR WEWPUMP PERMIT <br /> SSAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX VA 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> 1209► 499.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Trlplleetel <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WOR(DESCRIBED.TIIIB APPLICATION 18 MADE IN COMPLIANCE WAIT BAN <br /> JOAQUIN COUNTY DEVELOPMENT TNLE,CHAPTER 9-1 116.3 AND TINE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH BE(VICES.ENVIRONMENTAL HEALTH DIVRION. <br /> RE <br /> JOBADDRS/ORAPN#040 West W49hirn9tow Sthect CITLI <br /> r STOck QV. <br /> PARCEL BREIAPNI 4. 0 <br /> ['OWNER'SNAmEE 11L"��5- Mart�14 R0w1gK, ItAstee ADDRESS POB 5}0 ehryt'►7 GA 95663 RIONEILp�6 VCONTRACTOR V n�P�EJ QE IN I elk ADURESS PIS 5 IOW5t CA �} 9Q0tj1' ��/r(�p �pa] p � UCI �F[ NE SUBCONTRACTOR I itck F4Virohwq%t!alLVT-or o6e ADDRESS379 5 ears pl4cB UCI 9gL�'{IONa <br /> TYPE OF WELUPITMP: ❑ NEW WELL ❑ MPI ACEMfHT WELL A MONIFOBINO WELL S 6-9 0 OTHER IA l0ci4'F►041S <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL v J <br /> RYPE OF R1MPI <br /> ❑N. L3 Ren.1, H.P._— DEPTH PIMP BET R. FIRST WATER LEVEL O <br /> ❑ our SEnY10E WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BOnING __ e <br /> ❑DES(RUCTION: <br /> INtENOEO USETYPEOF WELL - - CONSTNUCIION SPECIFICATIONS A <br /> ❑ INDUBTRIAL ❑OPEN BOTTOM �� DIA.Of WELL EXCAVATION -(K DIA.OF CONDUCTOR CASING <br /> L1 <br /> OOMESTIC/PIVATE GRAVEL PACK/SIZE TYPE OF CABINO/eTEEL/PVC�VG DIA.OF WELL CASINO IRLq O <br /> ❑ PUTTUC/MUNICIPAL ❑DRIVEN DEPTH OF GROAT BEAL D F Ge� SPECIFICATION n <br /> ❑ IRRIGATION/AG ❑OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME E <br /> E MONITORING GROUT BEAL PUMPEO:❑Ys MX. CONCRETE PEDESTAL BY DRILLER:❑Yr (IN. 5 <br /> APPROX.DEPTH AU TGG LOCKINO CHEBTEn BON/STOVE PPE a <br /> PROPOSED CONSTRUCTIONIDRWNO METHOD: MUD ROTARY AIR ROTARY AWES CAKEL OTHER <br /> I HEAVEN CERTIFY THAT I HAVE PREPARED THIS A14LICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES,STATE LAWS,ANO RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER On LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> TIIIB PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN',COMPENSATION LAWS OF CALIFORNIA.- CONTMCTOn'9 HIRING On SUB CONTRACTING SIGNATURE CERTIFIES <br /> TGE FOLLOWING: •1 CERTIFY THAT IN THE PERfORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- TIE APPTCANT MUST CALL 24 MUM IN ADVANCE FOR ALL SEGURFO INSM"ONG AT 12M14ft 422. COMPLETE DRAWINO AT LOWER AREA PROVIDED. <br /> SIo X TIO. PrOJect MAa4so D.I. l 9 <br /> nor PIAN 10'.w 1.Sawa)IM.I. 11 •to 'OQ <br /> 1. NAMES OE STREETS OR ROADS NEAREST TO OR BOUNDING TINE MPERTrY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On MMSED <br /> 2. OUTLINE OF THE PROPERTY.01VINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXITING AND P101IORF0 S. LOCATION Of MLLR WITHIN RADIUS OF ONE HUNDNED FIFTY R. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAMS. ON THE PT)PETY On ADJOINING POOPEM. <br /> DEPARTMENT USE ONLY <br /> APPllcellen AaorpIM BY <br /> P`.P Impsn,len BYUHF <br /> Cnrnmwa.'_ Z (yG[J���__—�ViIDiW�F Fyy�� <br /> ACCOUNTING ONLY: AID# FRAC/ <br /> PE CODES FEE INTO AMOUNT REMITTED CIIfCN#ICASII RECEIVED RYDATE PFAMIOeF11VICE REQUEST NUMBER INVOICE <br /> Jaz - <br /> Pub.Health SEN.-ENID.173(3/96) ` <br />