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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES M7 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX-44%904 EAST WEBER AVENUE,STOCKTON,CA 9541-W <br /> (2091 469.3420 <br /> RON•REFUNDADLE FERNIT EXPIRES 1 TEAR FROM DATE ISSUED <br /> ANILICA-ION IS HERE BY M (Compute In Trlpkmio) <br /> JOAOUIN COI/NTy DEVELOPMENT 7NLe.CPERMIT To HAPTER 9-1115.3 AND THE gT NOA70CONSTRUCT TANWOR INSTALL THE VIOFIX COUNTY PUBLIC HEALTH BRIBED. ,HIS APPLICATION 18 M <br /> + _ AOE IN COMPLIANCE WITH BAN <br /> JOB ADDREB&7R APN, f b J �' /�•/')� E"RONMEHTµHEALTH CIVI81pN. <br /> �/J (' �T''�� T"/����—/.!`1�-1_CrTY � A ^ �C'� PARCEL a2F/AfN! <br /> OWNER'S NAME 4 A,A)/1 .{-A/ I f/D�Jdf-7 Y G C ADDRESS <br /> CONTRACTOR, <br /> 424 �. I` ZFFgNE,_ <br /> SA�ADDRESS <br /> BUR CONTRACTOR_ aL7 J7,H10NE 114-Eiggl�Z <br /> ADDRESS <br /> UC PHONE <br /> TYPE OF FNEW WELL ❑REPLACEMENT WELL ❑MCM70MING WFLL <br /> RISTALLAT"N ❑WELL SYSTEM ❑OTHER_ <br /> Ep REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EX FLA NCT yyEu♦ <br /> S u h 4Y N.x❑(iop�r r�/J q <br /> (TYPE OF PUMPI H.P.HF_.f!2 DEPTH PUMP SETZ0 •U <br /> R' FIRST WATER LEVEL <br /> ❑OUT-CF-BERVICE WELL ❑GEOPHYSICAL WELLSOO <br /> ❑DESTTRUCTION ❑ A BORING <br /> B <br /> INIENOm TYPE Of W <br /> ❑INDUSTRIALCON iTROC ON iMLeHCAIUD" (_AI <br /> OPEN BOTTOM DIA.OF WELL E)(CAVATION_p' A� <br /> DOMESTIC/PRIVATE ❑GRAVEL PACKBRE. n TYPE. r4A.OF CONDUCTOR CASING 0 <br /> OF CA61N0/STEEL/PVC ,mac <br /> PUSUCANVNICIPAI DRIVEN DIA.OF WELL CASING <br /> ❑ <br /> DEPTH OF GROUT SEALP D IPAIOATb N/AO ❑pTHER _ SPECIFICATION %(� <br /> OROUr SEAL INET ALLED SY d Y R <br /> LJ MONITORING GROUT BFIWpNAME �., tc <br /> GROUT SFM.PUMPED: Y.. N. Fr\ <br /> APPROX.OE1TH CO NC/(E'TE PEDEBTM BY GRILLER:❑Y. ❑Fb <br /> PROPS LOCKING CHESTER BOXISTO VE PIPE S r` <br /> EO CON STRUCTIONITMOLUNO METHOD MUD ROTARYs. <br /> AIR ROTARY AUGER— CABLE <br /> ,,Ir—`OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TYAT ONE WIN(WILL SE DONE IN <br /> I ; REGULATIONS OF THE BAN JOAoUIN COUNTY, HOME OWNER OR LICENSED AGENT' ACCOIOANCE 4'TTH BAN.IOAOUIN COUNTY pRDrNANCES,STATE LAWy, <br /> THIS PERMR IB ISSUED,I WTAIL NOT EMPLOY PERSONS SUBJECT TO WO\IG:RAN'y COM NA7UrE CERTIFIES THE FOLLOW":•I CERTIFY THAT W MID RULES <br /> THE FOLLOWHUG- 1 PEFiy ATgN LAWS OF CAI w IA.' T PERFONMANCIt OF THE WON(FOR ri18CV, <br /> CERTIFY 7HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS CONTRACTOKIS HIRING OR 9U8-CONTRACTING 910NATllRE CERTIFIES <br /> CALIFORNIA_' APPLICANTMUST CALL 14 HOURS IN ADVANCE FOR AL'.REOUIRLD INiPEC TIONi1 ATf20rn R "AL EMFLOY PERSONS DUOJECT To WO WSo <br /> ST. COMPETE ORAWINO AT LOWER AREA i COMPOIEATION LAWS OP <br /> elynod x � PRONGED. <br /> 1. NAMES OF STREETS OR ROAIIB PLOT ELAN ID..,v Io So.:.�6..1. <br /> NEAREST TO OR SOUNDING THE PFROPER7Y, <br /> 2,OUTLINE OF THE PROPERTY,OMNG DIMENSIONS AND NORTH DIRECTION. C LOCATION OF,HOUSE BEWAGE DISPOSAL SYSTEM O <br /> J. DIMENSIONED OUTUNF9 AND LOCATION OF ALL EXMTG ANO(`DSOP0EXPANSION OF SEWAGE bIBPOBAL SYSTEMS. R PROP'OOCD <br /> BTIRUC7UPE8,INClUG1N0 COVERED ARREWG <br /> AUCH AS PATIOS, 6. LOCATION OF WELLS OF <br /> DWVENAyg,g,AND WALK. WITHIN MgUB ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADAINM(I PRpPEF4Rry. <br /> ... e... i... <br /> ... >.. .. <br /> a <br /> i <br /> : <br /> .....:.. .:.. :. .... <br /> 1 <br /> DEPARTMENT UAE ONLY <br /> ApPllo.tbn Aeoept.d By \ �d <br /> DD.t.__.- <br /> .nul Inm.�„I.zD U � A.•.. <br /> .Pr.:Non ey <br /> �'>Rmpin,pKllon By <br /> De.InuSon In.P.oRon Sr L.t.��. <br /> ACCOL nHG ONLY: AID, <br /> FACT <br /> PE rOOES FEf INFO <br /> +I AMOUNT REMITTED HEC A AAH RECEIVED BY DATE REF01171SERVICE REOVEi HSR'S <br /> Ice <br /> c2 F0 7 <br />