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APPLICATION FOR WELL(PUMP PERMIT <br /> SAN.10AOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX SM 304 EAST WESER AVENUE,STOCKTON,CA 9%01-M <br /> (209)408.3420 <br /> NON-REFUNDARIE PERMIT El(PIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HERE BY MADE TO TME SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTmpkto�ANDIM INSTALL THE WOR(DESCRIBED.TWO APPLICATION IE MADE IN COMpUANCE WITH BAN <br /> JOAOUN COU'ITY DEVELOO'�P�M//EN'�T T/IIR__E•CHAPTER H-1116.3 AND THE 97ANDAMS OF SAN JOAGRRN COUFTTY PUSLIC HEALTH SUMCER,ENVIRONMENTAL HEALTH OPAI ON. <br /> JOS ADORESUOR.AMI a LJ W 1 11w � <br /> PARCEL BIZFlAiP;/ <br /> •�� CRY l ('_ PA (} <br /> OWNER'■NAME `�1_t� Y L{tCt`��\V 1.-,9,1rJl <br /> coNTRActoA ADrnFBS� CC Y YS3 UCE 4�cfflj PHONE E11.`�SV <br /> OUR CONTRACTOR g.. <br /> ADORE$O LI:J— PHONE 0 <br /> TVP!OF WfIJJ UMP. ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL I ❑OTHER <br /> 13INOT1AOLiATION 11 WELL SYSTEM REPAIR ❑CP.000LEC <br /> ONNT REPAIR (3VAPOR ExT_RAJ ION WELL 7 <br /> [3N—YJ R.P.A H. r 'y <br /> IT—DF MPI DEPEH RUMP-416:4� FIRST WATER LEVEL_J _ O <br /> ❑OUT-0FSERVICE WELL ❑GEOg4YO1CAL WELL P ❑ SOIL BORNO S <br /> 0 n c0 <br /> M <br /> -Pogo USE Typ of Wai CONSTRUCTION OPEOFICATHING <br /> ❑NIDUSTFOAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION CtA.OF CONDUCTOR CASINO A <br /> O <br /> PUBM OCAMOVATE ❑DRI VEL►ACKfBgE� TYPE OF CAIHN0/RTEELJPVC DIA.OF WELL CASINO <br /> ❑RIBUC/MVNICIPAL 13 DRIVEN 0 <br /> DEPTH OF GROUT SEAL _ SPECIFICATION A <br /> 11❑MONITO ING ❑OTHER GROUT SEAL B/STA LED RY GROUT SRAND NAME <br /> E <br /> MONITORING OROLR SEAL PUMpED:13 Y- (3 u. CONCRETEPEDEOTALSYDRRIER:❑Y- ❑N. S <br /> APPROX.DEPTH LOCKING CHESTER SOX/,COVE qpf <br /> S <br /> PROPOSED QOIIOTIRICTICNN1OWNG METHOD: MUD ROTARY AIR ROTARY AUGERCABLE OTHER <br /> 1 HESESY CERTIFY THAT I HAVE PREPARED THIS ROME o TNN AND THAT THE WOR(L""LL BE DONE N ACCORDANCE WTTN MAN JOAQUIN COUNTY ORDNIANCEO,KATE LAWS,AM RULES AND <br /> REGULATIONS OF THE SAN JOAQUN COUNTY.HOME OWNER OR LICEHOED AGENT'S NONATUIE CERTIFIES THE FOLLOWNG:'1 CERTIFY THAT N"PE7�ORMANCE Os THE WORE FOR WHICH <br /> THIS PERMIT It ISSUED,I ONALL NOT EMPLOY PERSONS BUOJECT TO WOAKMAN'S COMPENSATION LAWS OF CAUF0 LA-'COMRACTOWS HIRING OR SUBCONTRACTRIO SIGNATURE CENTORE <br /> THE FOUL 'I CERTIFY THA7 N THE PERFDRAIANCE OF THE WOIIC F-0R WMICH TORR PERMIT R ISSUED.I SHALL EMPLOY PER00NS WRJECT TO WORwAH•S CONLPENSAT10N LAWD 0 <br /> CAUFORM T AARN.'ANT MUST 2/HOURS p ADVANCE FOR AL'.RSOMRED INOPBCTIONS AT Sl SMi/7].COMPLETE DRAYANS AT LOWER AREA 0 <br /> Ow. N <br /> PLOT RAN LD,—w O-wi Red. •L. ^ <br /> 1.NAMES 4IMTS OR ROAD$NEAREST TO OR SOUNDING THE PROPERTY, 4_LOCATION O!HOUSE rn <br /> 2.OUTLINE OF THE PROPERTY,OWN DIMENSIONS AND NORTH DIRECTION, SEWAGE DISfpOAI SYSTEM OR PROPOSED <br /> $. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PPgPOOEGEXPANSION Of SEWAGE DIOPOOAL SYSTEMS. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUHDfWD FRT/FT. <br /> ON THE PRD►DRY OR ADJOINING PROPERTY. <br /> u�zLx I �, . ...... .. . .. .. <br /> ��, ........... . <br /> G Pr-n:. <br /> IC&A <br /> DEPARTMENT USE ONLY � - <br /> Applle.tlen Arogtrd BY_ C � �Y'llld D.ts .� 1 11 <br /> Dret,l Iropeetlen$Y— Dra. P–P I-P-11..By �zy,jy'--7^^ <br /> D.eutxtlen Irrp.e,l..+Ry D.t. <br /> D— <br /> Cenm.W <br /> ACCOUNTING ONLY: AID* FACA <br /> M CODES FEE INFO AMOUNT REMITTED CHIC CASH RECEIVED By DATE PgMR1MENVICE <br /> I REQUEST TILBIESgI )INVOICE <br /> i� <br />