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0 <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 /> (CompNu In Triplicate) <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.Title APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER B-111/5.3 AND T114Ej STANDAROS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION,a <br /> JOB AODRESS/OR APNI �L'� s ���7 LV 1( l CITY zc"�1�� _/.17"1 �PAAACCL�SIZEIAPNF �JSZ(may. <br /> OWNER'S NAME_ Aej(Td��-{,, )M ��I Y�� ADDRESS 1— -7,�LI") Cl r 77 7y'T'fy <br /> PHONE/ -( 7 —'7✓73�^ <br /> CONTRACTOR 1...-l�//�J'�7�.(�/� �/—I I//j/(CJ ADDRESS 709 j /Ci/ro , T ti�S.PJ,^.:I uC/ y��-/� /,�.PHONE.V_k +�-�J✓- <br /> PUB CONTRACTOR '� ADDRESS UC/ PHONE/ <br /> TYPE OF WELLVIJMP: XNFW WELL �,REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL BY87EM REPAIR ❑ CRoSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> ❑New❑Repei, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> RYPE OF PUMPI <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL <br /> # ❑ SOIL BORING S <br /> �DEBTRUCTION: <br /> INTENDED USE TYPE OF WELL �+CONSTRUCTION SPECIFICATIONS ti <br /> A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION n lL DIA.OF CONDUCTOR CASINO�+� D <br /> %-DOMESTM/PRIVATE 0-RAVEL PACK/StZE�_ TYPE OF CASINO/STEEL/PVC �P llC�.. DIA.OF WELL CASINO Lyi7. D <br /> 11 PUBLIC/MUNIC IPAL ❑DRIVEN DEPTH OF GROUT SEAL Ji/}�v , / SPECIFICATION I�-a /) J R <br /> C <br /> ❑ IRRIOATION/AG ❑OTHER GROUT SEAL INSTALLED BY /Jj-j�(��--- GROUT BRAND NAME C-�-P;�L(J F <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Y« [IN. CONCRETE PEDESTAL BY DRILLER:❑Yee U;<. 5 <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPf 5 <br /> PROPOSED CONSTRUCTIOWDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 IIAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> nEGULATIONS 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 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' T APPLICANT MUST A 24 HOWLS IN ADVANCE FOR ALL REQUIRED INSMT)AS AT 1201 4MJ422. COMPLETE DRAWINO AT LOWER AREA PROVIDED. <br /> Slpned X Tltl• ���� Det• /c—9— _ <br /> OT PIAN 1D�ew to Seelel 8oele to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERLY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTMG AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTVRES,INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ... Fes.. a <br /> PAYMENT <br /> 01 <br /> �r- .rIeq-1T? <br /> OCT '2'3 199$ <br /> Lit <br /> Avell <br /> aw <br /> Sky dGAI}UI[v C 0olvir 1 <br /> PUSUC HEALTH'S1 FlVICES` I 11 <br /> ENVIRONMENTAL.-EALfH DIV1Si �+ <br /> 1 <br /> / <br /> PARTMENT USE ONLY <br /> Appltoulen Aeeepled BY Del. O �___� Ar« I ^/t✓ <br /> Great IMP---BY Det. -� Pump n.vaetlen BY ��// ((11 Del. <br /> Deelne:tlen I—Peet B D.I. �i-+�2 <br /> rl-3.�B � / <br /> C n ne„t.. Q/ B i +w L I �s�sl a� - 20 �toLAT �i G �o�.E C L-� ` - � ov 5L <br /> a - UOI.ECI.✓I 0,v/'v6 78 w�ac w ar"A4Rvgt; Ca6+.e.vr/o 4V,� • 92 JA / , l��/3a��ou/r6 <br /> ACCOUNTINO ONLY: AID/ FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED SY DATE Pg"T/SERVICE REQUEST NUFARM INVOICE <br /> Pub Health Serv.-Enviro.173(1/97) <br />