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APPLICATION FOR WELL/PUMP PERM' <br /> SAT..40AQUIN COUNTY PUBLIC HEALTH SEr vICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IR HEM BY MADE TO THE BAN JOAQUIN COUNTY FOA A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION In MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBHC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AUDRESSM11 APO, 1444 Mariposa Road CITY Stockton PARCEL SIZE/APNI <br /> OWNER'S NAME USRentals ADDRESS 2081 E Charter Way PHONE, 948-9241 <br /> CONTRACTOR Clark Well , Inc. ADDRESS 2024 E Charter Hc, 371560 PaNE, 462-7676 <br /> OUR CONTRACTOR ADDRESS LIC( PHONE#- <br /> --TYPE OF WKbPUMP: ❑ NEW WELL - ❑ REPACEMEW WELL ❑ MONITORING WELL I ❑ OTHER _ <br /> N FFFI���7 ❑ nOTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL, J f <br /> ❑NwN❑nEPYI H.►.a_ DEPTH PIMP SET—FT. FIRST WATER LEVEL G <br /> RYPE OF PUMP( <br /> ❑ OVf-0FSERVN;E WELL ❑ GEOPHYSICAL WELL I ❑ ROIL BORING R J <br /> ❑DESTRUCTION <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> � DOMESToPIIVATE ❑OMVEL PACK/SIZE TYPE OF CASINOISTEEUPOC DIA.OF WELL CASINO —D <br /> ❑ PIBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> GROUT SEAL <br /> NSTALLED BY BMW <br /> W NAME E <br /> ❑ (MONITORING G ®OTHER GROUT REAL(PIMPED: C1Y. [IN. CONCRETEMPEDESTAL BY OPIUM❑Y— ON. S T-+ <br /> APPROX.DEPTH LOCKING CHESTER SOXMTOVE RPE S <br /> PROPOSED CONSTRUCTIONANOWNG METHOD: MUD ROTARY AIR AOTARY AUGER CABLE OTHER <br /> I HEYBY CERT( NAT I HAVE PREPARED THIS APPMAMN AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH CAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULED AHD, <br /> REGVIAT4+"O"E <br /> OU COUNT V. HOME MMFR OR MIC NBEO AOENT'B SIGNATURE CERFIFIEB THE fOLLOWINO:'1 CERTIFY THAT IN THE PERFOMVAANCF OF TME W01K FOR NNICN <br /> THIS PEN T MR PE BJECT TO BKMAN'e COMPFNeATOXUWBOFCALIFORNIA.' CORACTORSHIRING ORDUBCOWTHEFOLLH 1 T PER E OF THE -FOR WHICHTHISPERMITIRISSUED,1RNALLEMPLOYPERSONSSUBJECTTOWORMMCAUFORM S A 1 VANCE R ALL BEOTemm INePAT L_ OASESCOMPETEDRAWINGATLOWERAREBID_XTRI. Sec-TresPLOTFUNIw...He1NAME.OF STREEiR OOR EAREBT TO OR BOVNDINO TINE PM;Z i 1 A. LOCATION OF NOURE SEWAGE DIRPORAI SYSTEM OR PMIOSEO <br /> 3. OUTLINE OF TIME PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING AND PFOPISED R. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED r F FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,OPVMAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> WAj <br /> till <br /> PAYMENT <br /> eGE11fpD <br /> OCT 21 .1997i.. .: <br /> o PIi �' <br /> SAN JOAUUIN COUNTY.... <br /> PUBLIC HEALTH NT <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �'PC�•�� 6 S� R � � MEG.\FMIE"EM"1 )J -f <br /> 1 <br /> DEPARTMENT USE ONLY ` <br /> AnPIbNbR A..Tletl BY V A / /1 LWe I O/�� N.•____-2 / <br /> Q.•uH M•,U•Hbn BY U IVnP In•PeeBNR BY_' ( DSU <br /> OwVmlbn twn<IIeD BY D•U <br /> til gk)ZIAI�O 7 A �-- <br /> c..3mRX.: — � � iRPr�-. �.Pn � u_ ,�.-PSD ;-S =� Sb (>�(�J�.I.,, D✓1 rO,I,v.0.1..�— pa <br /> ACCOUNTING ONLY: AIDF FACT <br /> PE CODES FEE INFO I AMOUNT REMITTEDTIECK, ASM RECEIVED BY DATE PEPAITMFTRVICE REQUEST NUMBER INVOICE <br /> OSO jS b JDlaflfl b I0 �a <br /> Pub.Health SON. Enviro.173(1/97) <br />