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APPLICATION FOR WELL►PUMP PERMIT DO q`DJl✓� ` <br /> r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 0 o_/G(4' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O•BOX 388,304 EAST WEBER AVENUE,STOCKTON.CA 55201388 <br /> (209)468.3410 J ._ <br /> y� J <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR fpOM DATE ISSUED —"–•-�LR'� <br /> APPLICATION 19 HERE SY MADE TO THE BAN JOAWIN COUNTY FOR A PERMIT TO CONSTF <br /> RUCTkim ANDMn IINrSTALL THE WOR(DESCRIBED.THIS APPLICATION 16 MADE W COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 116.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OM910N. <br /> JOB ADORESSMFt APN! /f 32-3 �- �JQ CIT/ /-I A�d(' <br /> a PARCEL BIZE/APNI <br /> OWNER'S NAME- (1/•7� L� ADDRESS__ <br /> COMRACTOR ` - ADDRESS 2-O 2Sf E�ciT�v Jnr! .g 7�y PHONE I EJ( <br /> PUB CONTRACTOR ADDRESS <br /> LIC! PRONE IT <br /> TYPE OF WELLIPUMP• NEW WELL ❑PEFEACEM£NT WELL ❑MONITORING WELL! ❑OTHER <br /> ❑MOTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPCR EXTRACTION WELL F <br /> ��y(I/ <br /> - ❑RavNr N.P. 2 <br /> AVP£OF PUMP) DEPTH PUMP BET FT. FIRST WATER LEVEL d <br /> ❑OUT OF SERVE WELL ❑GEO"6ICAL WELL/ ❑ SOIL SORNO <br /> 11 DESTRUCTION- IC <br /> INTENDED USE TYPE OF WFLL CONSTRUCTION SPECIFICATIONS A <br /> ❑IFj�tlST'A' ❑OPEN BOTTOM DIA.OF WELL EXCAVATION <br /> LmY/ U1<111. <br /> < I A DIA.OF CONDUCTOR CASINO 0 <br /> DUBLICI UNIC AJ LJ GmvEN PACK/BRE L TYPE OF CABNVO/STEEVPVC //LL PV•` dA.OF WELL CASINO �/ (1 T <br /> ❑FIRtGATIO NICfPA1 ❑ORVEN DEPTH OF GROUT SEAL_ �L)Q E ^ <br /> /� Sf`ECIFICATgN /M <br /> ❑IRRIGATION/AO ❑OTHER GRgVT SEAL BNSTAt(HR EV C CL GROUT BRAND NAME�4 e W <br /> ❑MOMTONNG <br /> APMOX.pEI'RGRPLN.OUT SEAL PUMPED: •• ❑ <br /> 3/�II► CONCRETE PEIXSIAL BY DRILLER: ❑Ny S 11 <br /> H (/l' \ LOCKING CHESTER BOXMTOVE PNE \V 1(J <br /> RIOFOI ED CONSTRUCTON/ORWNO METHOD;MUD ROTARY AIR ROTARY AUGERS <br /> OTHERS ` 1 <br /> I IIEREBV CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WRl BE DONER <br /> E IN ACCORDANCE WITH BAN JOAN COUNTY ORpINANCES,STATE LAWS,AND RULES AND L� <br /> REGLRATIONO OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CTIFIES THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IN ISSUED,1 SHALL NOT EMPLOY FERSoNe SUBJECT TO WORKMAN'S COMPENSATION UW9 OF CALIFORNIA.•CONTRACTOR'S HIRING OR SUBCONTRACTING SgNATURE CERTIFIER 1 <br /> TETE FOLLOWIHp; •I CERTIFYTT <br /> TI PERION.IANCE OF THE WORK FOR WHICH TH18 PERMIT IB IBSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION UWS OF I <br /> CALIFORNIA.' TA/,PYN,),C(rA ] IS gL1gS IN ADVANCE FOR ALL REQUIRED INSPECTIONS 11T 12061 45936�7.COMPLETE DRAWING AT LOWER AREA PRO VI EO. <br /> Bb,,.e X •-mob 1///.E/'fi-,//Ll/ UP C/`/-(h/,,A` C <br /> PLOT PLAN IIN—1."".I Sc Iv 1 <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PR OPIRTY, tB <br /> I.OUTLINE OF THE PROPERTY.GMNG DIMEN6gNe AND NORTH DIRECTION. ��LOCATION OF HOUSE SEWAGE DISPOSAL TE SYSTEM DR PROPOSED <br /> S.DWENSIONEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION F BELLS THIN RADIUS <br /> STEMS. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S.LOCATION OF WELLS WITHIN RADRlS OF ONE HVNOIIED FFTY FT. <br /> ON THE PROPERTY OR ADJOINING FOMM , <br /> r <br /> �r?�U <br /> stp� i <br /> cwl <br /> _ . <br /> c Ai &, <br /> AYth �1 <br /> I <br /> A U(� :0 1996 <br /> Y <br /> .I <br /> i � C l f]///y,/ :P.ISLIGNAITHGEAVICE4 <br /> Q :lR0:NMM-- <br /> ENH . <br /> f"1 <br /> iAL-Fit71VrSiC)'. I <br /> I <br /> _ DEPARTMENTUSE ONLY <br /> ApPSa•tl.n Aw•vled BY <br /> Glenn ImP«GOR er _��/✓ L�/!/r 7 D•t• q/o% <br /> O..Ir�cll•n I­l BY — - <br /> _ b.n <br /> aee <br /> /G Sa v C zce S. <br /> ACCOUNTING ONLY: AID! \ <br /> FAC! <br /> ►E CODES FEE INFO AMOUNT ReArTED - R //CASH RECEIVED BY DATE PER MITIEERVICE REQUEST NUNIBIR INVOICE <br /> o3r�3a VVV <br /> i <br /> 7 03/x. 3 <br /> Pub.Heath Serv.•Enviro.173(3/96) J <br /> 1 <br />