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APPLICATION FOR WELLIPUMP PERMIT <br /> • AN JOAQUIN COUNTY PUBLIC HEALTH SERVICMF <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 469.3420 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TTlplleeul <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION le MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEWLOMMECNNT TITTLE,CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH 01"910N. <br /> JOB AODRESSMR APPEIUF 25 -100-LAY I � 0 J ��qTy TlF�,.� PARCEL SIZE/APN/ <br /> OWNER'S NAME_Ga Ta��p,��Ft��bb,,�i rT1aF1Tdl ADDRESS 16T00 W. T.w{CHA Fly -ryyy�� RHONE/&3�� <br /> CONTRACTOR V8W I-A.Jllirl-H ADDRESS P'O' �L 51 UC# y20904 PHONE#707-374-2815 <br /> Sun CONTRACTOR ADDRESS RLO ViSta2 CA 94571 UC/ PHONE/ <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL El MONITORING WELL# 2 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> ❑ <br /> OYPE OF PUMP( New 11 Renelr N.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O <br /> ❑ OUT-or SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSO A <br /> 11 INDUSTRIAL �❑�iEEOPENROTTOM DIA.OF WELL EXCAVATION_ 81t VIA.OF CONDUCTOR CAGING 12" D <br /> ❑ DOMESTICRTOVATE CI GRAVEL PACK/SIZE 3 � TYPE OF CASING/STEEL 9;c DIA.OF WELL CASINO `1 O <br /> ❑ PIRUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL 0 - 41 .Q 0 - 76 SPECIFICATION ��.1. �A10o�� Tr�.F.�.�{-�R <br /> ❑ IRRIGATKINIAO ❑OTHER GROUT SEAL INSTALLED BY rTIFERTITi(P GROUT BRAND NAMEORTElY- <4% ElaTGzlit� <br /> 13 MONITORING ya.,,�J &GG OG85F GROIN BEAL POMMO: ®Ys [IN. CONCRETE PEDESTAL BY DRILLER:®Y. [IN. 5 <br /> APPROX.DEPTH 1y <br /> _ 50' 1 to LOCKING CHESTER SOXIMOVE RPE X S <br /> PROPOSED CONSTRUCTIONIIDIUMINO METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE VATH BAN JOAQUIN COUNTY ORDINANCES,STATE"We,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TIIE WOR(FOR WHICH <br /> THIS PERMIT Ie ISSUED,I SHALL NOT EMR" PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT INTI ERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNI NE APRICAN VST n4 HOURS IN ADVANCE FOR ALL REQUIRED SFEOTIq le AT 1]OISL^SeIJ 23. COMPLETE DRAWING AT LOWER AREA/PROVVIDDEED. <br /> BIOnb TIII / (,(!w 1 <br /> MOT PIAN ID,.w Ie .LI Saha 'Ie <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PMR 4. LOCATION OF"OUSE SEWAGE DIGPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,CAVING DIMENSIONS AND NORTH DIRECTION. EXPANMON OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNFS ANO 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 PROPEWY. <br /> sae atiadnd <br /> I DEPARTMENT USE ONLY / /-( <br /> APPila.lbn Avaspled By .-K[•�///V-'L'I/ �Y DH. 1(/ 7 — A,. m7'S <br /> Orem In.Peanen Br D.Ie PnInP b•P.anen ar D.R. <br /> De.Rncnan Imneellen BY D.I. <br /> cam�nwK.: <br /> ACCOUNTING ONLY: AIDS FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PFRMITISERVICE REQUEST NUMBER INVOICE <br /> 3501 77 � � 0 <br /> Pub.Health Sew.-Enviro.173(3196) <br />