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00 �� ��-. <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICemplotl la TrlpRcste) — <br /> AM(CATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THF WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAO U1N COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIV1810N. <br /> JOB ADDRESSOR APHI 20599 S . PARADISE A II E . CTry TRACY PARCEL RIZE/APN1 <br /> OWNFR'S NAME DAIIII)Y & JERRY ROCHA ADDRESS 6551 H. ARBOR RD. TRACY h+1GNEI 835-7669 <br /> CONTRACTOR !fJIFIGS BROS. DRILLIPdG CO. , lK. ADDRESS 3525 PEL/-VCALE PIDDESTO LIc► 290813 PHONE, 545-1185 <br /> SUB CONTRACTOR //�� ADDRESS LIC/ PHONE/ <br /> TYPE OF WELL/PUMP; ��2!f NEW WELL ❑ REPLACEMENT WELL ❑ MONTTONNO WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ✓ <br /> ❑Naw❑Sepal, H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMPS <br /> ❑ OUT-OF-BERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL ROBING B <br /> ❑DESTRUCTION: <br /> INTEh DED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑,-yy OPEN BOTTOM DIA.OF WELL EXCAVATION 1211 DIA.OF CONDUCTOR CASINO O <br /> DOMESTICN"VATE L1J GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC P U C DIA.OF WELL CASINO 6 11 O <br /> ❑ MIBLICIMUNICIPAL ❑DmvEN DEPTH OF GROUT SEAL 10 0 1 SPECIFICATION B F IN T O P I T E R <br /> ❑ tRR1OATION/AG ❑OTHER GROUT REAL INSTALLEDBY 1-1 I 4' IPGS GROUT BRAND NAME B A R IUD �ryY E <br /> ❑ MONITORING GROUT SEAL PUMPED:Uy- ❑Ne CONCRETE PEDESTAL BY DRILLER:11 Y- (IN. 5 <br /> APPROX.DEPTH 280 ' V LOCKING CHESTER BOX/STOVE PIPE 5 <br /> PROPJSED CONiTRUCTIONIMELINO METHOD: MUD ROTARY X AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WALL BE DONE IN ACCORDANCE WITH SAN JOA COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REG"TtONS OF THE SAN JOAOUNI COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTORTMIRINO OR RUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORIONAN'S COMPENSATION LAWS OF <br /> CALIFORN <br /> IA <br /> .' THE APPLICANT MUST CALL 28 HOURS IN ADVANCE FOR ALL REQUIRED IN&PTCTIONS AT(201 881-8022. COMPLETE DRAWINq AT LOWER AREA PROVIDED. <br /> Sir—' x ae <br /> I I <br /> PLOT RAN ID.wv to Ileelel Beale I Ito <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO ON BOIrNDIFIIf THE PROPERTY. 0. L AT N O HOIISE S AO DI. S SV EM A D <br /> 2. OUTLINE OF THE PROPERTY,OtV1NG DIMENSION1 AND MOTH dnECTION. i j E PAH ON F SEWAGE d8 8A1 YST MS. <br /> 3. ISTFUCTMVORESD OVTLtWg AND INCLUDING COVEREDATION OF AREAS SUCL'EXISTING AND OROPOSED H AS PATIOS,DRIVEWAYS,AND WALKS. S ON THE PROPERTY OR ADJORM M PROOF ONE HUMORED FIFTY�. <br /> Li <br /> I <br /> t k <br /> i. <br /> 4 { <br /> A <br /> i I I I <br /> HgAI..T N E3l.i .ti" LTH SE <br /> fla c 40a, <br /> t�%t tun z N7 1 <br /> F <br /> I I I 1 <br /> I DF� TRENT VS!DNIr <br /> 3 <br /> Appli—flen Amopted By I I Det• <br /> Grout Inepeotlon By Pump Impeollen By I Dale <br /> Data <br /> Drretnrrtlen Imp�actnbn By �+ <br /> Cor.rn, A. �Jl J� 1' , 4i0 -^ -,LL 14 MElJ� gG�NrStE�j^� <br /> 1C LcN 3 ul _ �L/. d- e<-PJ �V l QLI(cf-*2O"IT <br /> ACCOUNTING ONLY: AIDS FACT <br /> PF CODES FEE INFO AMOUNT REMITTED CHEC I/CASH RECEIVED SY DATE ►6LMITAFAVICE REQl1EbT NUMBER INVOICE <br /> 3 U C) <br />