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APPLICATION FOR WELLIPUMP PERMIT <br /> 11N JOAOUIN COUNTY PUBLIC HEALTH SERVICL,..,, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 466.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complsh In TTioliests► <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTnUr.T ANO/OR INSTALL THF-WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WTTII S.IN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANOAROR OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOA ADDRESS/OR APNI 6Z L � <br /> T / DI-C � - i ��! CITY S 6L K-4&-%' PARCEL SIZFJl1W11 <br /> OWNEn'8 NAME Oc.. 6!:;o '•r[v�'Y6'h ADDRESS LLT/ LtJ. Lf�4 17�rcf �•�- y,IitONE R�G�/77-771S <br /> �vt« /•.�Z 7 5 y} I <br /> CONTRACTOR ✓/��'ir�J j� ADDRER8 .S 7 h v ! UCI �� 7G PHONE.� 3;7; <br /> R/>f IC U.^ 1 ^. vc <br /> SUB CONTRALTO 1 6�-) 1L, ADORE68Z LKS UCA_� /Lt/a P1/ONE <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELLS /1/J k-/— S ❑ OTHER _- <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> RVPE OF MMPI ❑N' ❑Ree.ir H.P. DEPTH NMP SET FT. FIRST WATER LEVEL <br /> ❑ DVT-OP SERVICE WELL ❑ GEOPHYSICAL WELL♦ ❑ SOIL BORING ,I <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - -- <br /> ❑ INDUSTRIAL ❑OPEN BOTTOMDIA.OF WELL EXCAVATION ( <br /> -L� DIA.OF CONDUCTOR CASINO �. -e- <br /> 0 <br /> .e- <br /> , <br /> ❑ DOMESTIC/PnIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC _ �(/�{ DIA.OF WELL CASING 211 - n <br /> PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL L rt., SPECIFICATION <br /> /�R9.E <br /> )siRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY_L)('r Ila--- GROUT BRAND NAME _ <br /> /,1ONITORING GROUT SEAL PUMPED:�Yw. ❑No CONCRETE MOESTAL BY DRILLER:❑Y- ❑No <br /> APPROX.DEPTH S- LOCKING CHESTER BOX/RTOVE PIPE , <br /> .S <br /> PROPOSED CONSTRUCTIONIDAILUNG METHOD- MUD ROTARY AIR ROTARY AUGER t;--- CABLE OTHER <br /> I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES ANO <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 18 ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR 8118-CONTRACTM4G SIGNATURE CERTIFIES <br /> THE FOL O: i CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFOR A.' HE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT(205)442J423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> ebn.a X S <br /> Tlti. <br /> OM. <br /> PLOT PLAN(Dr—to SoWel Se.1. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THEPROPERTY.PPERTY. 4. LOCATION OF HOUSESEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTEMS. <br /> J. DIMENSIONED OUTLINF,S 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 /> I` •r <br /> DEPARTMENT USE ONLY �) <br /> /) ' Are.`S V P y l O ! <br /> Applle.tlen AeeeeteA HY ! q q Dete <br /> Grout Imoeetlen 8Y R+nP inweetlen BY O.ta <br /> O.t. <br /> Oeametlen Imneeflon 8Y , <br /> 19 <br /> cemrner,t.• <br /> ACCOUNTING ONLY: AIDR FAC• <br /> INVOICE <br /> PE CODES I FEE INFO AMOUNT REMITTED CHE t� ASH RECEIVED BY DATE, P6IMITIS171VICE REGUEST NUMBER <br /> /Alll / <br /> i <br /> i <br /> Pub.Health Serv.-Enviro.173(3/96) <br />