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r <br /> a <br /> APPLICATION FOR WELL/PUMP PERMIT Fl <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 9521�2r,i�i, <br /> (209)466-3420 <br /> ROR•REFURDAILE PERMIT EXPIRES I YEAR FROM DATE 133V <br /> "lots In Tr}Rntsl <br /> APPLICATION NB HERE by MADE TO THE BAN JoAGUN COUNTY FOR A PERMIT TO COMTINCT ANURM NOTALL THE WOR(DfSCHIND.TIPS APPLICATION 19 MADE IN COMPLIANCE MATH SAN <br /> JOAQUIN COUNTY <br /> 1]EVELOPMFpfr TR12,CHAPTER S. <br /> 1115.3 <br /> 1 15..{ m <br /> 3 AND THE STAHDNMe/�OF BAN JOAOUW COUNTY FUKJC HEALTH SERVICES,ENVIRONMENTAL HEALTH IrillmoN`. <br /> JOB AOD# S"MAPIA_ L YO e 1l:C Amt Cary AQAN'[�`- � PARCELsREURds �✓ ` —3I�_�' <br /> OW7NER'S NAME, PML F_)A i k -- ADDRESS 'VZ-Q W. -JASPM fl 74L PRONE r <br /> CONTRACTOR Ai{+e Geo �1yl r yJ. L I AMM9. VU.. Z PHONE y <br /> SUS CONTRACTOR ADDRESS LJCP PHONE <br /> TYPE of MMIgs F, ❑ NEW WEL'. ❑ REPLACEMENT WELL ❑ MaMromm WELL r ❑ OTHER_ <br /> ❑ NBTALLATION ❑ WELL SYSTEM REPAIR ❑ CRDsbCoHNECT REPAIR ❑ VAPOR EX!RACtN)N WELL+ J <br /> ❑ .r.❑ PUMP HR.or. H.P_ DEPTH P NET FT_ FIRST WATER LEvEL.M 29 J-E f+ RS <br /> O <br /> (TYPE OF PUMP! <br /> I] OUT-0F•SERVICE WELL ❑ GEOPHYSICAL WELL A BOIL sORSNo 8 <br /> ❑DESTRUCTION' <br /> lNTOID IETyps OF WELL RMTR&STMN MmMkum <br /> �f ,1 A <br /> 11NDIISTMAL 11 OPEN BOTTOM ORA.OF WELL EXCAVATION G. 1',lt rT rJ1A.OF CONDUCTOR CASINO b <br /> ❑ OOMESTocnwvAtE ❑GRAVEL PAL-KnmE TYPE OF CAST J Mtt tr%m DIA.OF WELL CABNNO b <br /> 13MMJCMIIFICWAL VEN �— DEPTH OF aRaw REAL DCPI& SPECIMATION 111- <br /> 13 WMAtIONIAG <br /> v❑ IBSOA7pNIAG ❑OTHERS GROUT SEAL INSTALLED BY E j6�,OROUP BRAND NAME f <br /> gSMOMPOIYNG GROUT REAL PUMPED;[IV. CONCIIETE PEDESTAL BY Y.a ❑Na S <br /> APPROX.OEPTTI�-L -EE 4 LACNIMG CHESTER soxmrOVE PIPES <br /> PROPOSED COMMIN 1CTIONMRILUNG METHOD; MUD ROTARY ^AIR ROTARY AUGER_ CABLE OTH A6E <br /> 1 Ww"Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE V40W WILL M DONE N ACCORDANCE YAM SAN JOAQUIN COUNTY OPPNANCES.STATE LAWS.AND RULES AND <br /> "COULATIONS OF THE BAN JOAGIMR COUNTY. HOME OWNER OR LPCENSQ.I AGENT'S SIGNATURE CE#rFW09 THE'POLLOWINae 7 CERTFV THAT N THE FEAMPMANCE OF 7HE WOM FOR WHICH <br /> THS PEFI MIT IS ISSUED.1 SHALL NOT EMPLOY PERSONS RMLECT TO WORBMAN'S COMPENSATION LAWS OF CAIWOMA.• CONTRACTOR'S HIlENG OR SULCONTRACTNG WMATUM CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT N THE PEMORSMANVCE OF THE WORK FON MMICHPErdwr ISBU <br /> RBEri.1 SNALL EMPLOY PERSONS SUBJECT TO WOMMAWS COMFM/BATbN LAWS OF <br /> CALKOIWIA.' RHI!AFPICANT MUST! 24 HO=N ALL 'NIIIm MOM AT I3Y.SI♦Bs� COMPLETE COMITE DRAWING AT LOWATEA PIOVIMD <br /> Slrmd X Rte►+ /� Do. <br /> FLOW PIAN STisw to S"M bads <br /> r. NAMES OF STREETS OR ADS PIE OT TO OR BOUNDING THE PROPERTY. •. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLSNE OF 711E PROPERTY.ONIHq DIMER#SIOM AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 3. DIMENSIONED OUTLIES AND LOCATION OF ALL EXMrIHe AND 1'NOFONED S. LOCATION OF WIFLIA WITTBN KNOW@ OF ONE HUNDRED,FIFTY FT. <br /> BTRUCTIAES,INCLUDING COVEND MEAS SUCH AS PATHOS.DRSVEWAYB,AND WALK@. ON THE PROPERTY'ON ADJOINING PRDIERTY. <br /> r Von <br /> 1 <br /> OWARTMENT UIE ONLY t, <br /> A.,#saRliw,A~d e► Data <br /> Irr1� <br /> Gfmfi k*PaaSen By_ t' DatsAsnP Y-pwtlsn eY Oah <br /> Destmatl.n ki.pa.ilan a, Dais <br /> ACCOUATING ONLY: AOI FAC• O <br /> !m 0016 <br /> PE CODES FEE NFO AMOUNT RT]YSTTIM CHEC"MASH %vcqVIwvv GATE FYMIETIS Q E <br /> Z-11 a 9 <br /> Pub Health$erv.•Enviro.173(1187) <br />