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,AJ <br />0.n 0-iggrg.g <br />`'2!6q xgEp 6 IT P1 <br />• <br />' <br />• <br />OWN NOINNO/U <br />• <br />Of 11 m .71 <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br />(209) 469-3420 <br />NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Omelets In Triplicate) <br />APPLICATION IS HERE BY MADE TO TIIE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORE DESCRIBED. THIS APPLICATION IS MADE IN COMPUANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9 -1 I 1 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOS ADDRESSKIR AM/ r A or ./f)j'. f(.)1LJ cm Tito r int, PARCEL SIZEMPNO °Of "... 150 -e-/'O <br />OWNER'S NAME P/1!", ti 6 a rci e r ADDRESS 2- s 1-rei cis, on/L.1A, (.4 PHONES <br />CONTRACTOR 51411 FA reclwIcv ,-('T7 Annivss12.606rtifitk.56r, Att/46 ff/pcoit PRONE .20/S-N-212-, <br />SUB CONTRACTOR V‘jrce) ex E IA MO I /2j-vtC2 Ao.,,..115.5" CAe br, sie 4 1241L 1;3'Stiff-4; iVq 7 pitt286'-/CE4 <br />TYPE OF WELLIPUMP: 0 NEW WEIL 0 REPLACEMENT WTI L 0 MONITORING WELL S 0 OTHER <br />0 INSTAI LAT ION 0 WELL SYSTEM REPAIR 0 CROSS•CONNECT REPAIR 0 VAPOR EXTRACTION WELL / J <br />O N,,., 0 Flusle HP. (woo PUMP SET FT. FIRST WATER UWE 0 <br />FTYPE OF PUMPI <br />0 OUT OF•SERVICE WELL 0 GEOPHYSICAL WELL S E "OIL BORING 0 -10 30 <br />0 DESTRUCTION' <br />INTENDED USE TYPE OF W IL CONSTRUCTION SPECIFICATIONS A <br />El INDUSTRIAL DOPES BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO D <br />0 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASINGOSTEEUPVC DIA. OF WELL CASINO 0 <br />0 PUBLIC/MUNICIPAL 0 DRIVEN DEF'TH OF GROUT SEAL SPECIFICATION 4 <br />0 IRRIGATION/AG D OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br />0 MONHORING <br />APPROX. DEPTH <br />GROUT SEAL PUMPED: D v.. 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />CONCRETE PEDESTAL BY DRILLER' DV,. ON,, S <br />S <br />PROPOSED CONSTRUCTION/DfULLINO METHOD. MUD ROTARY AIR ROTARY AUGER CABLE OTHER birV-i -A54 <br />111E11E11Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORE WILL RE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT S SIGNATURE CEFITIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORE FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALT NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA. THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 12001 ASS-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Slonod X C-.,e.a./K"Ln/Lf.- 71tIo <br />PLOT PLAN (Draw IT Sulol Sudo to <br />NAMES OF STREETS OR ROADS NEAREST TO OR POUNDING THE PROPERTY. <br />01/TUNE OF THE PROPERTY. GIVING DIMENSIONS AND NORTH DIRECTION. <br />J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES. INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION Of SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />D.. /MO( <br />AutUtIon Accuud <br />Grout InopectIon BR <br />DEPARTMENT USE ONLY <br />B)/71-7/Q(40-7. DRS 102696, <br /> Dote P.", Impaction BY <br />Au, <br />DeetroctIon InopootIon By <br /> <br />Dee <br /> <br />Comm.,,,.: <br />ACCOUNTING ONLY: AIDS FAC# <br />M CODES FEE INFO AMOUNT REMITTED CHECKS/CASH R E1VED ST DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />3,r) I tiCI 11),3 Nil) )254> iD / 0 rd 7 0.3d-s74,1