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APPLICATION FOR WELLIPUMP PERMIT <br /> 1i(t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> [ �k � ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 q - l <br /> (209) 468-3420 l T <br /> �J NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> L� lA (Campllb in TrlpReetll <br /> APPLICATION 19 HERE SY M TO THE 8N JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED.TH19 APPLIC ION 19 MADE IN COMPLIANCE WNH SAN <br /> JOAQUIN COUNTY DEVELOPM NT TITLE,CHAPTER B-1 15. AND IE <br /> '�-�`�BTANDARDB Of BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRON ENTAL HEALTH DIVISION. <br /> ScV Corte � wX• <br /> JOB ADORESSIOn APNE c�vti1 �L.r� 4�r-sD1�P�r- I,o„)T1�ti1 _ __ _ city PARCEL SIZEIAPNF <br /> OWNER'S NAME T-[,l' _ a ADDRESS PFroNE I �] <br /> CONTRACTOR L a� oy� V� ADDRESS 35 <br /> RUn CONTRACTOR l_L/ ADDRESS W "Co <br /> IyIONE/�� <br /> TYPE OF VYELLIPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL El MON---w---► H OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM PEPAIn ❑ CR09S.CONNECT REPNR ❑ VAPOR EXTnAC7tON WELL s J <br /> ❑flew IIeP■Ir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMPI <br /> ❑ OUTor-SERVICE WELL ❑ OEOI`FIVSICAL WELL+I ❑ SOIL BOR1N0 S <br /> ❑DESTRUCT ION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1! A <br /> ❑ 1NOuSIMAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION C� OIA.bF CONOUCTORCASIN D <br /> ❑ DOMEBt1en"VAIE ❑OnAVEL PACKIBIZE TYPE OF CA9FNOlST EEUI'VC OIA.OF WELL CASINO D <br /> ❑ PUBtKIMUNICIPAL ❑DRIVEN DEPT14 OF GROUT SEAL SPECIFICATION R <br /> ❑ InRIOATHONIAG ❑OTHER GROUT SEAL INSTALLED SY�1�1 _ GROUT BRAND NAME E <br /> JR MONITORING GROUT SEAL PLIMPCv! ❑Yee ❑No CONCRETE PEDESTAL BY DRILLEII:9Y■■ ❑N. S <br /> PT APPROX.DEH - __ LOCKING CHESTER Btl OVE FM' S <br /> PROPOSED CON1tRUCT10NIDFILUNG METHOD:-MUD ROTARY Ain ROTARY UOER CABLE OTHER <br /> I HrV OY CERTIFY THAT I HAVE PREPARED TH16 APPMATtON AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUfN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWM!'I CERTIFY THAT W THE PERFORMANCE OF TITS WORK FOR WHICH <br /> THIS PEnMri 19 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN4 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S MFVM OR SUBCONTRACTM SIONATURE CERTIFIES <br /> TIFF FOLLOWING: CERTNFX THAT TIIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMPT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMMSA NON LAWS OF <br /> CALIFORNIA.*M <br /> UST LL 24 HOURS IN ADVANCE FOR ALL REOUIRE4 INervoTIONS AT 12051 4aS-s422. CCOMPI-ETE OFIALING AT LOWER AREA rROVHOEO. <br /> 9lorwd X TIU• ". \ Leo 0�1 4■te <br /> PLOT MAN 0■w to Seigel seal[a ��'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOINO THE PROPERTY. 4, LOCATION Of HOUSE BEWAGE DISPOSAL SYSTEM OR PMPOSEtr <br /> 2. OUTLINE OF 714E PnOPERfY,DIVING tWAFN9fONS AND NORTH DIRECTION. EXPAI i"ON OF SEWAGE 11181`09AL SYSTEMS. <br /> 3. DIMENSIONED OUTUNP.S AND LOCATION OF ALL EXISTING AND PROOPOSEO 4. LOCATION OF WELLS WFtWH RAIMVS Of ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLVOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPEFTt'Y OR ADJOINING PROPERTY. <br /> MENT,...,.E,.. ; <br /> .J..E.,......... '.V. <br /> . :MAR <br /> c LT <br /> N 0()1VEC <br /> M <br /> y_ 1'1TA EA�. I� <br /> IVI IOF,i <br /> d <br /> 4n` <br /> ... <br /> .. <br /> QDA <br /> . .. . . . <br /> - M <br /> _ DETARTMENT USE ONLY <br /> hPPll■■Lien Aeaesled ny n�L 4r t ( u-'"" OM■ � � h.■ <br /> Omit kopeallon By D■IP P1rrp Inepeellen By Date <br /> D"Irt allen MeneellennBy <br /> Cernmerh■: \ 6 <br /> ACCOUNTING ONLY: AID# AC/ <br /> PE CODER FEE INTO AMOUNT REMITTEO CHECKWICASH RECflVEO■y DATE P9tllMTI1ERVICE REQUEST N SER INVOICE <br /> TI <br /> 3 o sos <br /> Pub Health Serv..EnVITo.173(1197) <br />