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APPLICATION FOR WELLIPUMP PERMIT <br /> •SAN JOAQUIN COUNTY PUBLIC HEALTH SERV <br /> ENVIRONMENTAL HEALTH DIVISION <br /> RO. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 4693420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION 19"ERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMn INSTALL THE WOR(DFSCRIBEO.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> "AMIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1116.3 AND THE STANDARDS OF RArN OAOUIN COUNTY PUBLIC NEALTH SERVICES,ENVIRONMENTAL HEALTH 111,111. <br /> JOB AOORE89/Ofl APN/ 255-310-24 V4611J.l'LI�A.�✓h T Tracy <br /> PARCEL 6REIAPH# <br /> OWNER'9NAME Milton Birkham ADDRESS 97 West Durham Ferry PHONE 1835-4723 <br /> CONTRACTOR V&W DriIIinq ADDRESS P.O. Box 51 ITS/7ZQ9Qt] PHONE/707-374-291 <br /> 1.o V's <br /> Sue CONTRACTOR ADDRESS ta, CA 94571 UC/ PHONE 9- <br /> TYPE OF WEU/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL IH MONITORING WELL O 1 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> HYPE OF MMP) 11New❑ ME <br /> Re'* N.P. DEFT"PIMP MT—FT. FIRST WATER LEVEL p <br /> 11F <br /> OUT OSERVICE WELL 11GEOPHYSICAL WELL# ❑ MOIL DORNG q <br /> 11 DESTRUCTION: <br /> INTENDED UBE TYPE OF WELL CONSTRUCTION BPECIFICATIONoa A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM yJ(']J DIA.OF WELL EXCAVATION TTHIP DIA.OF CONDUCTOR CA91 0 � p <br /> ❑ DOMEBTICA VATE 10 GRAVEL PACKISIZE O � TYPE OF CASINGISTEELIPVC CVP. DIA.OF WELL CASING .1�� .�A�. aa..,� O <br /> ❑ PIBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROVE SEAL 0-41 I SPECIFICATION CHIB1t 'i'G B3l111111L q <br /> 1F-y1 IRRGATIONIAG ❑OTHER GROUP SEAL INSTALLED BY tramne GROUP BRAND NAME E <br /> ITMONITONNG c!1 GROUT SEAL PIMPED:fly. [IN. CONCRETE PEDESTAL BY DRILLER:LjY.. [IN. 5 <br /> APPROX.DTMH -API LOCKING CHESTED BOX/STOVE RPE X S <br /> PROPOSED CONBTRIICTION/ LUNG METHOD: MUD ROTARY AIR ROTARY X AUGER CABLE OTHER <br /> I"May CERTIFY THAT I HAW PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN 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 WOR(DR W"ICII <br /> THIS PERMIT IM ISSUED,I SHALL MOfMPLOY PERSONS SUBJECT TO WORKMAN-@ CONIMBATMN LAWS OF CALIFORNIA.- CONTRACTOWS HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING! '.I <br /> CAUFORNIA. ?M APRICIFY Irt , ',STT/JCAATHE <br /> LL 22�4PERFORMANCE <br /> ADVAN E FDA U REOUIWHICH <br /> RED OPEC'PERMIT <br /> RBBA/T�/120,(41�S�M1123. COMPLETE DRAWING AT LOWER AMAWORKMAN'S <br /> AgVIDED.6ATIOM LAWS OF <br /> BlOnee%� rMWYt/! Tltl JIlRlJr.P/WV Dele�f <br /> -913 <br /> ROT PLAN IN.to SQ.I.,S m. 't0 <br /> 1. NAMED OF BTREFTS OR ROAD8 NEAREST TO On BOUNDING THE PROMITTY. 4. LOCATION OF HOUSE SEWAGE DlameAL SYSTEM OR PMomaw <br /> 2. OUTLINE OF THE PHOPEGRY,GIVING DIMENSIONS AND NORTH DIDECTION. EXPANSION OF DEWADE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY rt. <br /> STRUCTURES, <br /> .INCLUDING <br /> GCCOVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALK8. ON THE PROPERTY OR ADJOINING PIIDPETDY. <br /> • Os, tY.lLLA4A.•.. .i. .: i.. y. ..... <br /> �J DEPARTMENT USE ONLY <br /> Applh.0en ACOWtd BY ��.7� I//l D.I. �' Arr <br /> OreU Impeellen By D.I. N"P Inlpepllen By Dae <br /> De.eratlen ironecUon BY v.le <br /> cemmenl.: <br /> ACCOUNTING ONLY: AID# TACO <br /> PE CODE4 FEE INFO AMOUNT REMITTED CHECK#/CAD" RECEIVED BY DATE PERASTISERVICE REQUEST NUMBER INVOICE <br /> 3�0/ 6 <br /> Pub.Health Serv.-Enviro.173(3/96) <br />