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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 2ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In TTIPlicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORE89AJfl ANI 10055 Henry Rd CRY Escalon PARCEL SIZEIAPN' <br /> OWNER-9 NAME Mike Hilvers Construction ADDRESS 11057 E. West RioZn7, Ripon PRONE' 573-6508 <br /> CONTRACTOR Hennings Bros. Drilling AoDMss3525 Pelandale, mod. uG, 290813 PHONE' 545-1185 <br /> SUB CONTRACTOR <br /> ADDRESS UC' <br /> qqyy PHONE I <br /> TYPE OF WELLIPUMP: MNEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL' ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL' <br /> ❑ <br /> N.❑Rep.1r M.P. DEPTH NMP SET <br /> ITYPE OF MMPI FT. FIRST WATER LEVEL O <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL' ❑ SOIL BORING 9 <br /> ❑DESTRUCTION: <br /> INTENDED UEE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 13INDUSTRIAL <br /> M <br /> INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION YI !I ✓ T C( DIA.OF CONDUCTOR CASINO ��,� N A D <br /> WADOMESTIC".VATE RAVEL PACK/SIZE_ TYPE OF CASINGISTEEL/PVC PVL, DIA.OF WELL CASING YTY S [ <br /> ❑ MBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 1001 SPECIFICATION 160Sch I <br /> ❑ IRRIGATION/AG ❑OTHER / GROUT SEAL INSTALLED BY driller GROUT BRAND NAME_ Super gel E <br /> ❑ MONITORING L(� qy` GROUT SEAL PUMPED: ❑Y. ❑N. CONCRETE PEDESTAL BY DRILLER:❑Yr ®No 5 <br /> APPROX.DEPTH j V LOCKING CHESTER BOX/STOVE RPE S <br /> PROPOSED CONSTRUCTION/DRILLING METHOD- MUD ROTARY X AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW(WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> MGUUTIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AOENT'6 SIGNATURE CERTIFIES THE FOLLOWING: 9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBLONTMCTING SIGNATURE CERTIFIES <br /> THE FOLLOWIN I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FO WHICH THIS PERMIT ISI USO.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMMENSATTON UWS OF <br /> CAUFO HE ARRUCANT MUST CA 24 HOURS IN ADVANCE FOR ALL GUIREO INS 'CMR, 20SI 4{91'2{. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> BI'rn. X L, t( L t. TRI. c- [ D... 10-4-96 <br /> PL PULN (D,.w Re Seale) Gc,N. RP <br /> 1. NAMES OF STREETS OR ROADS NEAPEST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED n <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNF9 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 WALAS. ON THE PROPERTY OR ADJOINING PRD RTY. <br /> Wr_ll 51 TE I' <br /> \V� <br /> ,eat nz� � <br /> J ' 1 <br /> O <br /> O <br /> IzIhLEC 4 <br /> UC1 - H i 96 11Or4h e,� <br /> Ibaekls Rile <br /> I� <br /> DEPARTMENT USE ONLY (( ll Q�70 <br /> APPllc.11.n Aec«ted BY C Dae V Z �F Ary <br /> GreN lrn ' Z Pump ImP«Ilon By <br /> P«nen Br D.Ie D.I. <br /> D«u,cnon Imo«0 qB,y� <br /> Comment.:�4 — J�}�u,. N �V✓l <br /> ACCOUNTING ONLY: AID' / FAC( <br /> NVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED BY DATE PERUBTISERVICE REGUEST NUMBER I <br /> EM <br /> � r o.3a 58 <br />