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­ APPLICATION FOR ELL/PUMP PER"'T <br /> & -,JOAQUIN COUNTY PUBLIC HEALTH S- RICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE "SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLI� SERVICES,ENVIRONMENTAL HEALTH DIVISION. VITT <br /> v ,HEAL <br /> JOB ADDRESS/OR APN# T '�2 <br /> c ek—, <br /> —PARCEL IZFJAPNI_ <br /> owwws NAME �-)`4 ' <br /> ,v ADDRESS -V <br /> (cu, <br /> CONTRACTOR n, 7 <br /> "'A-CA ADORES <br /> L 4P. <br /> Lici,i <br /> -51("5 PRO N E# <br /> Ick,�1-cll) <br /> SUB CONTRACTOR ADDRESS A-1 e 1,4-,r-7 PHONE 9 <br /> TYPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL '0MONITORING WELL# 4 11 OTHER <br /> 11 INSTALLATION WELL SYSTEM REPAIR CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL v <br /> (TYPE OF PUMP) 11 New El Repair M.P. DEPTH PUMP SET Fr. FIRST WATER LEVEL 0 <br /> 11 OUT-OF-SERVICE WELL GEOPHYSICAL WELL# 11 SOIL BORING ET <br /> 0 DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA410N8 <br /> QQ <br /> 0 INDUSTRIAL IJ OPEN SOT-TOM DIA.OF WELL EXCAVATION 6- DIA.OF CONDUCTOR CASING A <br /> D <br /> 11 DOMESTIC/PRIVATE 11 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC 1 a v DBA.OF WELL CASING D <br /> 11 PUBLIC/MUNICIPAL 13 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> 11 IRRIGATION/AG F1 OTHER GROUT SEAL INSTALLED BY(-N 1­ze41tj�,j GROUT BRAND NAME <br /> MONITORING GROUT SEAL PUMPED„t3Yee [1­NeJ CONCRETE PEDESTAL BY DRILLER:CIY- EIN. <br /> APPROX.DEPTHLOCKING CHESTER BOX/STOVE PIPE_ <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY .AUGER fi CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 09 ISSUED,I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> "') 4 <br /> L Z- <br /> Title L Date <br /> AJ <br /> 0 (Draw to scale)SmIs to <br /> 1. NAMES OF STREETS OR ROADS HART TO OR BOUNDIN HE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> .......... <br /> 4­k <br /> ............ <br /> ............ ........ .. ...... <br /> ... .. <br /> ......... .......... <br /> F <br /> fitl <br /> ........ .... <br /> ........... ............ ...... ................... ...... ..... <br /> .......... ....... ................... . .......... .......... ....... <br /> ........... ............ <br /> ........... ...... ...... <br /> .................... .......... ......... ....... <br /> .......... ...... <br /> ....... .... <br /> ........... <br /> ........... <br /> .... ........ ........ ............. ............ .......... ......... <br /> ............. <br /> ............................ <br /> : � I : � _ <br /> ................. ......... ............. .............................. <br /> L <br /> DEPARTMENT USE ONLY <br /> Applim0o.Ac.optedd By Date Arm <br /> G-1 I-pectl�By Date Pump Impaction 9 Date <br /> D-t­0..?-p-t1ort a Data <br /> C­"w <br /> ACCOUNTING ONLY: AfD# FACO <br /> PE coo" FEE INFO AMOUNT REMITTED QCHECKIb--ASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> �>cf <br /> C <br /> -zef c 6,c <br /> p <br /> 11 <br /> a HE <br /> Fit <br /> 71 <br /> 69 <br /> Pub.Health Serv.-Enviro.173(1/97) <br />