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l <br /> ` TION FOp WELLIPUMP PERMIT ' <br /> f1 i S V COUNTY PUBLIC HEALTH SERVICES <br /> i0NMENTAL HEALTH DIVISION <br /> RO. BOX 388 304' .-ESTI WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 466.3420 <br /> i� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complat4 In Tripfiestal <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111`5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES;ENVIRONMENTAL HEALTH DIVISION. <br /> i JOB ADDRESSIOR APNS {c]S �� J I T1.4 `,''�QAC F" CITY!�'T-� <br /> IG4� �A PAIICEL SIMMONS <br /> //�� A.O. ' \OLa4 <br /> f OWNER'S NAME �<,2yV l';-yY ApDREes <br /> 4 { � —[_T2pCv.�A}P9S3'76 S PHONE <br /> Ltc, - ) esZ <br /> CONTRACTOR�.%2yf-yADDRESS 'fzt 'Ag:1Tl UC/ PHONES <br /> 23ES w!y1 a Si�•s <br /> SUBCONTRACTOR G\ECZ:#n ADDRESSISM- -, <br /> > <br /> )•yG <br /> tIS <br /> Ql &Z�. HCI�1221eH PHONE/ y(,s—H7rZ <br /> TYPE OF WELL/PUMP: /{— NEW WELL 11 REPLACEMENT WELL 9VONTTORINO WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROB&CONNECTI REPAIR ❑ VAPOR EXTRACTION WELLS J <br /> ❑New❑RepSlt H.P. DEPTH PUMP SET -I FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ., ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING B <br /> I <br /> ❑DESTRUCTION:— <br /> INTENDED-USE <br /> ESTRUCTION:INTENDEDVSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS'+ A <br /> 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p <br /> f ❑ DOMESTIC/PRUVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC I: DIA.OF WELL CASING p <br /> ❑ P1BLIC/MUNICIPgI ❑DRIVEN DEPTH OF GMAT SEAL \\ li. SPECIFICATION q <br /> 11IMIOATION/AG ❑OTHER GROUT SEAL INSTALLED BY UfZ GROW BRAND NAME E J <br /> j I ;KVIONRORING H GROUT SEAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLEn:❑ [IN.Ne 5 <br /> APPROX.DEPTH 0 LOCKING CHESTER BOX/STOVE PPE S <br /> t <br /> PROPOSED CONSTRUCTION/DRLUNG METHOD: MUD ROTARY AIR ROTARY I',AVGER X CABLE OTHER <br /> t <br />{1 I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE NroiK 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 WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA'- HEA CANT MV CALL= )INS IN ADVANCE FOR ALL REGURED INSPECTIONS AT 1200)4611 COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> . /, <br /> 61Sned � ♦ Tltle D.I. <br /> T - <br /> PLOT PAN Ipre.v to 6oNe1 SeNe�_' <br /> NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE POPERTY,.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> I1iT I O O MW-3 ! Building - - <br /> I <br /> I Bldg. <br /> k AAI <br /> _ _. Ensting MpmtoTng Well Loratirns <br /> Cax Property-Mr.Ed's ® ai Heinz Prooertv '_....;. <br /> _._._ __._._._._._. p•ccezed Vex Gcu tat=•`-cnrz� <br /> I East 11N Street � � ,_ ,_ _.a Wel Lccpom= r <br /> DEPARTMENT USE ON Y <br /> AppPcotlon Accepted BY I7-17-?7. Dela <br /> t Grout Impeetlon By Det. Pump Imp.ctlon By. Det. <br /> i Deetrwtlen Impaden Sv yyyyyy ,! D.I. j <br />�Y Cemmentc �z. <br /> ' I <br /> k,. <br /> ACCOUNTING ONLY: AIDS FAC# { <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK!/CASH RECEIVED BY DA'Tli PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> S 89-vr� tel!5 7 l5 "�0l3 e$-2-- <br />